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College  of  ^tpstrians  anb  #>urgron5 
ILibrarp 


SAUNDERS'  QUESTION-COMPENDS,  No.  12. 

ESSENTIALS  OF  MINOR  SURGERY, 

BANDAGING,  AND  VENEREAL  DISEASES. 

ARRANGED  IN  THE  FORM  OF 

QUESTIONS  AND  ANSWERS. 


PREPARED  ESPECIALLY    FOR 


STUDENTS  OF  MEDICINE. 


BY 

EDWARD    MARTIN,  A.  M,  M.  D, 

Clinical  Professor  of  Genito-Urinary  Diseases;  Instructor  in  Operative  Surgery  and 

Lecturer  on  Minor  Surgery,  University  of  Pennsylvania;  Surgeon  to  the  Howard 

Hospital;  Assistant  Surgeon  to  the  University  Hospital,  etc.,  etc. 


SECOND  EDITION,  REVISED  AND  ENLARGED. 


78  ILLUSTRATIONS. 


PHILADELPHIA: 

W.    B.    SAUNDERS, 

925  Walnut  Street. 
18  93. 


Copyright,  1890-1893,  by  W.  B.  Saunders. 


-KP/// 
m3 


PREFACE  TO  SECOND  EDITION. 


Tpiis  little  volume  has  been  thoroughly  revised  and 
brought  up  to  the  present  standard  of  surgical  practice. 

A  larffe  number  of  the  illustrations  have  been  redrawn 
and  engraved,  and  an  entirely  new  set  of  Bandaging  cuts 
inserted  ;  for  these,  as  well  as  the  descriptions,  the  author 
has  been  indebted  to  the  American  Text  Book  of  Sur- 
gery. 


ni 


PREFACE. 


The  modest  aim  of  this  volume  is  well  expressed  in  the  title-page. 
It  is  designed  to  aid  the  student  in  acquiring  the  principles  primarily 
essential  to  a  thorough  knowledge  of  the  subjects  treated.  Many 
omissions  have  necessarily  been  made,  omissions  which  each  must 
supply  by  reading  and  study  after  the  huny  and  rush  of  the  medical 
school  has  given  place  to  the  quiet  of  beginning  practice. 

If  the  principles  here  laid  down  enable  the  overworked  student 
to  formulate  his  knowledge  upon  subjects  usually  treated  as  of 
minor  importance  in  the  surgical  course,  but  in  reality  chiefly  essen- 
tial in  the  early  years  of  his  professional  life,  the  author  will  feel 
well  repaid  for  the  time  and  labor  bestowed  upon  the  work. 


V 


TABLE  OF  CONTENTS. 


PAGE 

The  Eoller  Bandage, 1'7 

Eoller  Bandages  of  the  Extremities, 22 

of  the  Trunk, 27 

of  the  Lower  Extremity, 35 

Head  Bandages, •    •  41 

T-Bandage, 49 

Many-Tail  Bandage, 49 

Crossed  Bandage  of  the  Perineum, 50 

Handkerchief  Bandage, 51 

of  the  Head, 51 

of  the  Trunk, 53 

of  the  Extremities,      .........  56 

Plaster-of-Paris  Bandages, 59 

Adhesive  Plasters  and  Strapping, 62 

Knots  and  Sutures, 64 

Antiseptics, "^1 

Sponges, '^'4 

Catgut, 75 

Silk, 75 

Dressings, 75 

Drainage, 77 

Antiseptic  Operation, 77 

Anaesthetics,      79 

Counter  Irritants, 87 

vii 


viii  TABLE  OF  CONTENTS. 

PAGE 

Depletion, 92 

Cnpj)ing, 93 

Leeching, 94 

Transfusion,      95 

Hypodermic  Medication, 96 

Fracture-Drwssings, 99 

Luxations, Ill 

Venereal  Diseases, 118 

Chancroid, 118 

Gonorrhoea, 124 

Chronic  Gonorrhoea, 140 

Syphilis, ««.*#«#•••#•••  153 


ESSENTIALS  OF  BANDAGING. 


For  what  purposes  are  "bandages  applied  ? 

The  general  indications  for  the  appHcation  of  bandages  are,  to 
retain  spHnts  and  dressings,  and  to  make  pressure. 


THE  ROLLER  BANDAGE. 

Describe  the  roller  bandage. 

The  roller  bandage  may  be  made  of  muslin,  calico,  gauze,  or  any 
thin,  strong  fabric.  Usually  unbleached  muslin  is  used.  A  piece 
from  three  to  twelve  yards  in  length  is  procured,  the  selvedge  is  re- 
moved, and  it  is  then  torn  into  strips  varying  in  width  from  half  an 

Fifi.  1. 


Double  and  Single-headed  Roller. 

inch  to  three  inches.  Each  strip  is  freed  of  loose  threads  at  its 
edges,  and  is  rolled  tightly  in  the  form  of  a  cylinder.  The  rolling 
may  be  from  each  end  toward  the  middle,  forming  two  cylinders ; 
this  is  called  the  double-headed  roller. 

How  is  the  bandage  rolled  ? 

This  is  usually  done  upon  a  small  machine  provided  for  the  pur- 
pose.    Where  this  is  not  at  hand,  a  core  should  first  be  made  by 
2  17 


18  ESSENTIALS   OF   BANDAGING. 

folding  one  end  of  the  bandage  upon  itself  for  about  eight  inches  of 
its  length.  This  doubling  is  again  folded  in,  and  the  process  is  con- 
tinued till  a  central  mass  is  formed.  This  core  is  made  still  larger 
by  placing  it  upon  the  thigh  and  including  one  or  two  feet  of  the 
length  of  the  bandage  by  rolling  it  bet^seen  the  thigh  and  the  palm 
of  the  hand.  When  the  centre  is  sufficiently  large,  it  is  taken  be- 
tween the  thumb  and  middle  finger  of  the  left  hand  while  the  con- 
tinuation of  the  strip  passes  between  the  thumb  and  the  index  finger 
of  the  right  hand.  By  seizing  the  body  of  the  bandage  in  tlie 
right  middle,  ring  and  little  fingers,  with  the  hand  in  supination  and 

Fig.  2. 


Eolling  the  Bandage. 

carrying  the  latter  to  pronation,  the  cylinder  is  made  to  perform  a 
half  revolution,  with  the  thumb  and  middle  finger  of  the  left  hand 
representing  the  supports  of  its  axis.  As  the  right  hand  is  again 
earned  to  suiDination,  a  certain  portion  of  the  length  of  the  bandage, 
passing  between  its  thu'jib  and  index  finger,  is  wound  tightly  upon 
the  core  ;  again  grasping  the  latter  and  repeating  these  movements 
the  roller  bandage  is  gradually  completed.  It  should  be  so  tightly 
wound  that  it  is  impossible  to  push  out  the  core  by  a  firm  pressure 
of  the  thumb  upon  one  end  of  the  cjdinder,  and  should  be  so 
thoroughly  cleared  of  loose  threads  that  there  is  no  possibility  of 
these  impeding  the  surgeon  when  the  bandage  is  applied. 


THE  ROLLER  BANDAGE.  19 

How  should  a  bandage  be  pinned  ? 

Small  safety  pins  should  be  used,  when  obtainable.  Tlie  terminal 
extremity  of  the  bandage  should  be  folded  upon  itself  for  one  or 
two  inches  of  its  length,  and  one  or  two  pins,  depending  upon  the 
width  of  the  bandage,  should  secure  this  reduplication  to  the  turns 
beneath.  Where  ordinary  pins  are  used,  the  points  should  be  di- 
rected downward  and  should  always  be  buried  in  the  folds  of  the 
bandage ;  when  applied  to  secure  dressings  of  the  extremities  the 
points  should  be  directed  toward  the  fingers  or  toes. 

Name  the  parts  of  a  roller  bandage. 

The  free  end.  left  after  the  formation  of  the  cylinder,  is  termed 
the  initial  extremity  ;  the  end  enveloped  in  the  core  is  termed  the 
terminal  extremity.  Further,  the  bandage  has  an  upper  and  a  lower 
border,  and  an  internal  and  external  surf  ice.  Tlie  cylinder  formed 
by  the  rolled  bandage  is  termed  the  body  of  the  roller. 

How  is  a  roller  bandage  applied  ? 

The  bandage  is  nearly  always  applied  from  left  to  right.  The  body 
of  the  roller  is  taken  in  the  palm  of  the  right  hand  in  such  a  way 
that  the  thumb  lies  parallel  with  the  long  axis  of  the  cylinder  ;  the 
external  surface  of  the  initial  extremity  is  applied  to  the  surface  to 
be  covered  in,  and  is  held  in  place  by  pressure  of  the  thumb  of  the 
left  hand  until  it  is  caught  by  the  bandage  carried  around  the  part. 
This  first  turn  is  further  secured  by  adding  an  additional  circular 
turn. 

If  the  limb,  or  the  part  to  be  bandaged  is  cj'lindrical  in  shape,  it 
may  be  covered  in  by  the  application  of  spiral  turns,  or  those  which 
pass  upward,  each  one  overlapping  the  other.  Where,  however,  a 
conical  part  is  to  be  covered,  the  spiral  reversed  turns  are  required. 
In  surgical  dressing  all  of  the  following  turns  may  be  re(iuired  : — 

1.  Circular  turns,  or  those  which  pass  around  a  part,  one  directly 
overlying  the  other.  Nearly  all  bandages  are  started  by  two  circalar 
turns. 

2.  Oblique  turns,  or  tlwse  in  which  the  bandage  passes  up  the 
limb  without  overlapping,  leaving  a  space  between  each  turn.  In 
applying  loose  dressings  to  bruises  or  extensive  burns  this  bandage  is 
of  service. 

3.  Spiral  turns,  or  those  in  which  the  entire  surface  involved  i^ 


20 


ESSENTIALS   OF   BANDAGING. 


Fig.  3. 


The  Oblique  Turn. 


covered  by  the  bandage.  These  differ  from  the  obhque  turns  only 
in  tlie  fact  that  each  time  tlie  bandage  is  carried  around  the  hmb  it 
overlaps  the  preceding  turn.  In  bandaging  poorly 
developed  arms  and  legs,  or  in  aj^plying  dressings 
to  the  chest  or  abdomen,  these  turns  are  used. 

4.  Recurrent  Turns. — By  means  of  these  the  end 
of  a  stump  or  the  top  of  tiie  head  is  covered  in. 
The  initial  extremity  of  the  roller  being  secured, 
the  latter  is  carried  directly  across  the  apex  of  the 
projecting  surface  and  well  down  upon  the  other 
side,  where  it  is  held  in  place  by  the  finger  of  the 
bandager,  or  of  an  assistant.  The  bandage  is  now 
carried  back  to  its  point  of  starting,  caught  by  the 
finger,  and  carried  as  before  across  the  surface  to 
be  covered.  Eacvh.  of  these  turns  overlaps  the  other 
for  two-thirds  of  its  width.  When  the  surface  to 
be  protected  is  entirely  covered  hy  the  bandage  the 
latter  is  earned  once  or  twice  circularly  about  the 
part,  thus  securing  the  loops  made  by  reversing  the 
direction  of  the  bandage  in  applying  the  recurrent  turns. 

5.  Spica  and  figure-of-eight  turns  are  those  in  which  the 
bandage  forms,  by  obliciue  turns — first  passing  upward  and  then 
returning  upon  themselves — two  loops,  which  present  the  form  of 
an  eight,  ^y  overlapping  the  crossings  of  these  loops  a  series 
of  angles  or  spicas  is  formed.  For  instance,  a  bandage  is  carried 
obliquely  upward  across  the  knee,  around  the  back  of  the  thigh 
obliquely  downward  across  the  knee  again,  and  around  the  back 
of  the  upper  part  of  the  calf,  returning  to  the  point  of  starting,  thus 
forming  a  figure-of-eight.  If  these  turns  are  repeated,  each  over- 
lapping its  predecessor,  and  passing  upward  or  downward,  a  series 
of  angles  or  spicas  will  be  formed. 

6.  The  spiral  reversed  turns  are  those  in  which  the  bandage  is 
folded  back  upon  itself,  thus  accommodating  its  surface  to  conical 
or  irregularly-shaped  parts. 

Describe  the  spiral  reversed  bandage. 

This  turn,  the  most  difficult  of  all  to  acquire,  consists  in  folding 
the  bandage  over  so  that  the  surface  previously  in  contact  with  the 
skin  is  turned  outward  with  each  reverse.     This  is  accomplisihed, 


THE  ROLLER  BANDAGE. 


21 


after  having  fixed  the  bandage  by  one  or  two  circular  turns,  by 
overlapping  the  latter  as  though  an  oblique  were  about  to  be 
formed.  In  place  of  this,  however,  the  thumb  of  the  left  hand 
fixes  the  bandage,  while  the  latter  is  folded  over  by  carrying  the 
hand  containing  the  roller  from  the  position  of  supination  to  one  of 
pronation.  The  body  of  the  roller  is  now  passed  beneath  the  limb 
from  the  right  to  the  left  hand  ;  not  till  it  is  received  in  the  left 
hand  is  traction  exerted.  This  traction  causes  a  perfectly  smooth 
fold,  and  accurately  adapts  the  bandage  to  a  conical  or  hregular 


Fig.  4. 


Fig.  5. 


Fig.  6. 


The  Spiral  Reversed  Turn. 


surface.  Tliis  process  is  repeated  each  time  the  bandage  is  carried 
around  the  limb,  or  as  often  as  required  to  accom[)lish  perfectly 
uniform  pressure.  An  effort  should  be  made  to  liave  the  angles 
formed  between  the  turned  down  border  of  one  fold  and  the  lower 
]:)order  of  the  next  i)erfectly  in  line.  It  must  be  remembered  that 
this  line  represents  the  portion  of  the  bandage  which  exerts  the 
greatest  pressure,  hence  it  should  not  be  placed  where  such  x>ressure 
would  be  undesirable,  as,  for  instance,  over  the  ulna  or  over  the  crest 
of  the  tibia. 

What  points  must  be  especially  observed  in  applying  the 
roller  bandage  ? 

1.  That  it  should  not  be  too  tight.  As  a  means  of  gauging  this 
point  when  limbs  are  bandaged,  the  fingers  and  toes  are  left 
exposed.  If,  after  the  application  of  the  most  elaborate  bandage, 
the  patient  complains  of  pain,  and  there  are  marked  signs  of  venous 
congestion,  not  relieved  by  elevation  of  the  part,  the  bandage  must 
be  immediately  removed  and  replaced  more  carefull}-. 

2.  That  it  should  fit  accui'ately  and  neatly  to  the  part. 


22  ESSENTIALS   OF  BANDAGING. 

3.  Tliat  if  firm  jncssure  is  required,  this  should  be  uniform.  In 
case  pressure  is  required  at  any  portiou  of  the  extremities,  the 
roller  buudage  must  include  the  whole  of  the  limb  lying  beyond  the 
point  of  pressure. 

4.  That  reverses,  recurrent  turns,  and  points  of  crossing  should  be 
secured  by  pins. 

Roller  Bandages  of  the  Extremities. 

Describe  the  spiral  of  one  finger. 

This  bandage  should  be  three-quarters  of  an  inch  wide,  and  one 
and  a  half  yards  long. 

The  roller  is  fixed  by  a  repeated  circular  turn  about  the  wrist ;  it 
is  then  carried  down  across  the  back  of  the  hand  to  the  finger,  the 
extremity  of  which  is  reached  by  an  oblique  turn.     The  whole 

Fig.  7. 


Spiral  of  Four  Fingers. 

finger  is  then  covered  in  to  its  palmar  extremity,  the  bandage 
passing  upward  by  means  of  spiral  or  reversed  turns  ;  on  reaching 
the  web  of  the  finger,  the  roller  is  carried  across  the  back  of  the 
hand  to  t'nc  point  of  starting,  and  the  dres.sing  is  completed  by  a 
cu'cular  turn  about  the  wrist. 

Describe  the  spiral  of  four  fingers  (gauntlet). 

The  roller  should  be  one  inch  in  breadth  and  five  yards  long. 

The  turns  are  precisely  the  same  as  in  the  spiral  of  one  finger. 
The  fir.'^t  finger  covered  in  is  the  index  of  the  right  hand,  or  the  little 
finger  of  the  left.  As  each  finger  is  completely  covered  the  roller 
is  carried  up  across  the  dorsum  of  the  hand,  once  around  the  wrist 
and  down  across  the  back  of  the  hand  to  the  next  finger.  The  thumb 
also  may  be  included,  if  necessary. 


ROLLER  BANDAGES  OF  EXTRE31ITtES. 


23 


In  cellulitis,  burns,  or  poisoning  involving  a  considerable  portion 
of  the  surface  of  the  hand,  this  di'essing  will  be  found  useful. 

Describe  the  spica  of  the  thumb. 

This  roller  should  be  three  yards  long  and  three -(luarters  of  an 
inch  wide.     It  may  be  ascending  or  descending. 

The  ascending  spica  of  the  tliinnh  overlaps  from  the  extremity  of 
this  digit  toward  the  wrist.  The  bandage  is  fixed  at  the  wrist  by  a 
repeated  circular  turn ;  is  then  carried  obliquely  across  the  metacarpus 
of  the  thumb  to  the  distal  extremity  of  the  iirst  phalanx,  around 


Fig.  S. 


Fig.  9. 


Gauntlet,  also  faking  in  the  Thumb. 


?p:ca  of  Thumb. 


which  a  circular  turn  is  made.  From  this  point  the  roller  is  carried 
across  the  dorsum  of  the  thumb  to  the  wrist,  half  around  the  wi'ist, 
obliquely  upward  to  the  position  of  the  circular  turn  around  the 
phalanx,  half  around  this  and  obhquely  downward  to  the  wrist. 
These  turns  are  repeated,  each  one  overlapping  its  predecessor 
toward  the  wrist  for  one-half  of  its  width,  till  the  dorsal  surface  of 
the  metacarpus  is  completely  covered,  when  the  bandage  is  com- 
pleted by  a  circular  turn  around  the  wriht.  The  angles  made  by  the 
crossing  of  the  ascending  and  descending  turns  should  be  placed 
exactly  in  lino  with  each  other,  slightly  toward  the  palmar  surface 
of  the  thumb. 
The  ciscending  spica  is  formed  in  the  same  way,  excepting  that 


24  ESSENTIALS   OF   BANDAGING. 

the  first  crossing  turns  are  made  as  near  the  wrist  as  possible,  and 
the  subsequent  turns  overlap  toward  the  phalanx. 

Describe  the  demi-gauntlet. 

This  roller  should  be  three  yards  long  and  one  inch  in  breadth. 

It  is  fixed  by  a  double  circular  turn  at  the  wrist ;  it  is  then  carried 
obliquely  across  the  back  of  the  hand  to  the  index  finger  of  the 
right  side,  the  little  finger  of  the  left.  It  is  looped  around  the  finger 
and  carried  back  to  the  wrist ;  after  a  circular  turn  it  is  again  carried 
across  the  dorsum  of  the  hand  and  looped  around  the  next  finger, 
and  again  carried  to  the  wrist.  By  the  same  turns  loops  are  carried 
around  the  remaining  two  fingers,  and  finally  three  or  four  figure-of- 
eight  turns  are  made  around  the  hand  and  wrist.  When  completed, 
the  back  of  the  hand  is  covered  in.  the  fingers  being  left  free. 

This  bandage  is  useful  for  retaining  dressings  on  the  back  of  the 
hand. 

Fi(i.  10. 


Spiral  reversed  ol  Upper  Extremity. 

Describe  the  spiral  reversed  of  the  upper  extremity. 

This  bandage  should  be  twelve  yards  long  and  one  and  one-half 
inches  in  width.  It  should  be  applied,  when  possible,  with  the 
back  of  the  patient's  hand  turned  toward  the  face  of  the  dresser. 

The  bandage  is  fixed  by  a  repeated  circular  turn  at  the  wrist ;  it 
is  then  carried  obliquely  across  the  back  of  the  hand  and  circularly 
around  the  four  fingers,  held  in  close  apposition,  at  the  level  of  the 
second  joint  of  the  little  finger.  Two  or  three  spiral  reversed  turns 
are  now  made,  running  up  the  hand  to  the  web  of  the  thumb,  the 
angle  of  reverses  being  directly  in  the  middle  hne.  The  remaining 
portion  of  the  dorsum  of  the  hand,  and  the  metacarpal  bone  of  the 
thumb  are  covered  in  by  two  or  three  figure-of-eight  turns.  These 
are  made  by  continuing  the  bandage  obliquely  downward,  around 


ROLLER  BANDAGES   OF  EXTREMITIES.  25 

the  thenar  eminence  of  the  right  hand,  the  hypo-thenar  eminence 
of  the  left,  across  to  the  opposite  border  of  the  hand  and  up  again 
over  the  dorsum,  the  upper  border  of  the  bandage  making  an 
angle  with  the  upper  border  of  the  descending  turn,  which  is  in  line 
with  the  angles  formed  by  the  reverses.  These  turns  are  overlapped 
toward  the  wrist  until  the  back  of  the  hand  is  entirely  covered.  The 
wrist  and  lower  portion  of  the  forearm  are  now  included  in  two  or 
three  circular  turns.  As  soon  as  the  forearm  begins  to  increase  in 
size,  spiral  reverses  will  be  recpired  to  make  the  bandage  fit  neatly. 
These  are  made  as  described  above.  The  body  of  the  roller  is  turned 
over,  so  that  its  upper  border  looks  do"\vnward,  the  roller  is  passed 
beneath  the  arm  from  the  right  to  the  left  hand,  and  the  bandage  is 
drawn  taut  so  that  the  fold  lies  perfectly  smooth.  The  roller  is  car- 
ried over  the  limb  and  is  again  passed  to  the  right  hand,  and  another 
reverse  is  formed.  This  is  continued  until  the  elbow  is  reached. 
Here  figure-of-eight  turns  are  required,  though  reverses  may  be 
used.  The  former,  however,  hold  their  position  much  better.  The 
figure-of-eight  turns  are  made  by  canying  the  bandage  upward 
obhquely  across  the  bend  of  the  elbow  to  a  position  somewhat 
above  the  condyle  ;  here  the  bandage  is  continued  around  the  back 
of  the  arm,  till  it  reaches  a  point  above  the  opposite  condyle  ;  it  is 
then  carried  obliquely  downward,  forming  an  intersection  with  the 
first  turn,  and  around  the  back  of  the  forearm,  overlapping  the  upper 
spiral  reversed  turn  toward  the  elbow  joint.  It  is  again  carried 
across  the  front  of  the  elbow  and  around  the  back  of  the  arm,  over- 
lapping the  preceding  turn  downward  ;  these  turns  are  repeated 
until  those  overlapping  downward  and  those  overlapping  upward 
are  separated  posteriorly  by  a  narrow  inteiTal ;  this  is  covered  in  by 
a  circular  turn,  and  the  bandage  is  continued  up  the  arm,  generally 
by  sphal  turns,  since  this  portion  of  the  limb  is  very  nearly  cylin- 
drical. If  there  be  much  variation  in  shape  or  size,  however,  spiral 
reversed  turns  may  be  required.  The  bandage  is  finally  completed 
just  below  the  shoulder  by  a  circular  turn,  and  secured  in  place 
by  pins. 

Describe  the  spica  of  the  shoulder. 

This  roller  should  be  ten  yards  long  and  two  and  a  half  inches 
wide.  The  shoulder  may  be  covered  in  by  either  causing  the  turns 
to  ascend  or  descend ;   in  the  ascending  sjjica  the  turns  overlap 


26 


ESSENTIALS   OF  BANDAGING. 


upward,  in  tlie  descending  spica  they  overlap  iu  tlie  opposite  direc- 
tion. 

The  ascend  ill  r/  spica  is  formed  by  fixing  tlie  bandage  by  a  repeated 
circular  turn  around  the  arm  as  close  to  the  axillary  folds  as  possible. 
The  bandage  is  now  made  to  pass  obliquely  upward,  across  tjie  cir- 
cular turn  upon  the  outer  aspect  of  the  shoulder,  directly  across  the 
chest  if  the  dressing  is  being  applied  to  the  right  side,  or  across 
the  back,  if  the  dressing  is  applied  to  the  left  side,  beneath  the 
axilla  of  the  opposite  side  of  the  body,  back  again  to  the  injured 
shoulder,  and  across  the  outer  aspect  of  the  arm,  intersecting  the 
first  turn  and  forming  an  angle  with  it  directly  in  the  middle  line 
of  the  shoulder.  The  roller  is  then  carried  under  the  axilla,  over 
the  shoulder,  overlapping  the  first  turn  for  two-thirds  of  it.i  width, 
across  the  thorax  to  the  opposite  axilla,  and  back  again  to  the  side 

Fig.  11. 


Ascending  Spica  of  the  Shoulder. 

which  is  being  bandaged,  making  another  angle  by  intersecting  the 
second  turn  on  the  outer  aspect  of  the  shoulder.  These  turns  are 
repeated  till  the  shoulder  is  covered  to  the  root  of  the  neck,  the 
extremity  of  the  bandage  being  pinned  at  any  convenient  point. 

The  descending  spica  diifers  from  the  ascending  only  in  the  fact 
that  the  first  spica  turns  cross  at  the  root  of  the  neck,  and  are  then 


ROLLEIi,  BANDAGES   OF  THE  TRUx^JK.  27 

overlapped  downward  till  tlie  circular  turn  about  the  arm  is  reached 
and  partially  covered  in . 

This  dressing  is  useful  in  injui'ies  of  the  shoulder.  It  exerts 
uniform  pressure  upon  this  part,  if  properly  applied,  and  enables 
dressings  to  be  retained.  Care  must  be  taken  to  see  that  the  axillary 
turns  make  no  undue  pressure  upon  the  blood-vessels. 

Fig.  12. 


Figure-of-eight  of  Both  Shoulders. 

Describe  the  Velpeau  bandage. 

This  bandage  should  be  fourteen  yards  long  and  two  and  a  half 
inches  wide.  For  its  proper  application  the  hand  of  the  side  to  be 
bandaged  must  be  placed  upon  the  opposite  shoulder  at  the  base  of 
the  neck,  the  elbow  being  closely  applied  to  the  chest.  As  excoria- 
tion always  results  from  keeping  skin  surfaces  long  in  contact,  a 
sheet  of  lint  or  absorbent  cotton  should  be  placed  between  the  arm 
and  the  body. 

The  initial  extremity  of  the  roller  is  placed  at  the  angle  of  the 
scapula  of  the  sound  side  ;  the  bandage  is  then  carried  over  the  top 
of  the  shoulder  of  the  injured  side,  downward  to  the  outer  aspect 


28 


ESSENTIALS   OF  BANDAGING. 


of  the  middle  third  of  the  humerus,  and  thence  directly  across  the 
chest  and  around  to  the  point  of  starting  ;  this  turn  is  repeated  to 
fix  the  roller.  Having  reached  the  side  of  the  chest  in  the  axillary 
line  of  the  sound  side  on  repeating  this  turn,  the  bandage  is  carried 
transversely  across  the  back,  around  to  the  front  of  the  body,  across 
the  outer  aspect  of  the  arm,  covering  in  the  external  concljde  of  the 
hum  eras  at  a  point  so  low  that  the  olecranon  cannot  be  seen  from 
the  front,  and  on  around  to  the  point  of  starting,  when  it  is  again 
carried  over  the  shoulder  and  down  across  the  middle  third  of  the 
humerus,  overlapping  the  first  shoulder  turn  at  this  point  for  about 

Fig.  13. 


^B 

^H 

^^^^ 

^9HH 

^^^^^^^^K     '   ^    l  I             ^^^^ 

i^^^^^^^^^HSs^^'  ^-^^F^    ^^^^^^^1 

^^^B  \  '■■ '  1  ^w^ 

pw*— ■     "^^W    W^M 

^^^K^.l.i'''- -""^^ 

"w       w^m 

^K  /""■""'"'"^ 

~-"'^"        /      flj 

^-■-     \   \ 

t ,        ^ 

^^^B 

^BBft££ii3l 

■^l^tfiK 

>#:^''-.<'1@jB^^^E 

Velpeau  Coiapleteil. 


five-sixths  of  its  width.  Another  circular  turn  of  the  bandage  is 
now  made  about  the  body,  overlapping  the  first  circular  turn  for 
about  one-third  of  its  width  ;  this  is  followed  by  a  shoulder  turn 
overlapping  as  before  (five-sixths).  The  bandage  is  continued  by 
alternating  the  shoulder  and  the  circular  turns,  and  the  overlapping 
is  so  planned  that  by  the  time  the  shoulder  turns  have  reached  the 
point  of  the  elbow  the  circular  turns  have  ascended  as  far  as  the 
wrist.  The  anterior  border  of  the  shoulder  turns  should  extend  to 
hut  not  heyoncl  tlie  olecranon.,  as  otherwise  this  last  turn  is  liable  to 
sli]),  thus  loosening  the  whole  bandage.     The  roller  may  be  pinned 


ROLLER  BANDAGES   OE  THE  TRUNK. 


29 


at  any  jooint  where  it  ends,  preferably  somewliere  in  the  axillary 
line,  or  j)Osteriorly,  where  the  terminal  extremity  is  out  of  sight. 
This  bandage  is  useful  in  the  treatment  of  fractures  of  the  clavicle. 

Describe  the  Desault  roller. 

For  this  bandage  a  wedge-shaped  pad  and  three  distinct  rollers  are 
required.  The  first  roller  fixes  the  pad  in  the  axilla,  the  second 
secures  the  arm  to  the  side,  and  the  third,  by  pressure  upon  the 
dorsal  surface  of  the  upper  portion  of  the  forearm,  forces  the  shoul- 
der upward  and  backward. 


Fig.  14. 


Desault — First  Roller. 


The  first  roller  should  be  five  yards  long  and  two  and  a  half  inches 
wide. 

The  pad  being  placed  in  the  axilla  of  the  injured  side,  with  its 
base  applied  to  the  axillary  folds,  four  spiral  turns  are  passed  about 
the  chest  and  over  the  pad,  securing  the  latter  in  position.  To 
prevent  these  turns  from  sHpping  down,  the  bandage  is  further 
secured  by  passing  it  obliquely  across  either  the  chest  or  the  back, 
depending  upon  whether  the  dressing  is  applied  to  the  left  or  the 


30 


ESSENTIALS   OF  BANDAGING. 


right  side,  o^•er  the  top  of  the  shoulder,  under  the  axilla  of  the 
sound  side,  and  back  again  to  the  position  of  the  pad.  The  roller  is 
then  continued  across  the  opposite  aspect  of  the  thorax,  over  the 
shoulder  and  beneath  the  axilla  of  the  sound  side,  and  is  carried 
back  to  the  pad.  Two  or  three  of  these  turns  are  made,  holding 
the  bandage  firmly  in  jjlace. 


Fig.  15. 


Desaiilt— Second  Koller. 


Tlie  second  roller  should  be  seven  5^ards  long  and  two  and  one-half 
inches  wide. 

It  is  made  up  of  spiral  turns  embracing  the  chest  and  the  arm  of 
the  injured  side,  and  overlapping  downward  from  the  point  of  the 
shoulder  to  the  olecranon.  The  upper  turns  are  applied  loosely ;  the 
lower  are  drawn  as  tight  as  is  compatible  with  the  comfort  of  the 
patient.  The  object  of  these  turns  is  to  force  the  shoulder  outward 
by  drawing  the  elbow  close  to  the  side,  the  axillary  pad  acting  as  a 
fulcrum  ;  each  turn  should  overlap  its  predecessor  for  two-thirds  of 
its  width. 


ROLLER  BANDAGES   OF   THE  TRUNK. 


31 


The  third  roller  should  be  seven  yards  long  and  two  and  one-half 
inches  wide. 

Its  proximal  extremitj^  is  fixed  in  the  axilla  of  the  sound  side  ; 
the  body  of  the  bandage  is  then  carried  oblKiuely  across  the  chest, 


Fig.  16. 


Desault — Third  Roller — Completed  Bandage. 


over  the  top  of  the  injured  shoulder,  down  along  the  posterior  sur- 
face of  the  humerus,  and  forward  and  upward  around  the  upper 
fifth  of  the  ulna  (the  forearm  being  flexed  at  a  right  angle  and  lying 
across  the  chest)  to  the  point  of  starting.  It  is  then  continued  pos- 
teriorly across  the  upper  portion  of  the  scapula  of  the  sound  side 
over  the  top  of  the  injured  shoulder,  directly  downward  from  this 
point,  parallel  with  the  humerus,  to  the  upper  fifth  of  the  fore- 
arm, around  the  back  of  which  it  is  carried,  and  is  then  continued 
upward  and  backward  across  the  dorsal  surface  of  the  thorax  to  the 
point  of  starting.  These  turns  are  repeated  at  least  three  times, 
each  one  exactly  overlying  and  not  overlapping  its  predecessor.  The 
bandage  may  be  pinned  at  any  convenient  point.  The  dressing  is 
finally  completed  by  slinging  the  forearm  at  the  wrist. 

The  Desault  bandage  is  applied  in  the  treatment  of  fractures  of 


32  ESSENTIALS   OF  BANDAGING. 

tlie  clavicle.  The  third  roller  is  u.seful  in  dressing  fractures  of  the 
acromion  or  coracoid  process,  or  of  the  anatomical  neck  of  the 
humerus.  It  is  sometimes  applied  in  the  after-treatment  of  luxa- 
tions of  the  humerus. 

Describe  the  spiral  of  the  chest. 

This  requires  a  roller  seven  yards  long  and  from  three  to  six  inches 
in  width. 

The  bandage  is  started  by  a  circular  turn  around  the  waist,  once 
repeated.  The  roller  is  then  carried  up  to  the  axilla  by  successive 
spiral  turns,  each  overlapping  its  predecessor  by  one-half  the  width 
of  the  bandage.  When  the  whole  chest  is  thus  covered  in,  the 
bandage  is  further  secured  by  pinning  it  in  front,  carrying  it  over 
one  shoulder,  and  pinning  it  behind  to  the  circular  turns.  From  the 
second  point  of  fixation  the  bandage  is  carried  over  the  opposite 
shoulder  and  is  finally  pinned  to  the  circular  turns  in  front.  This 
practically  forms  a  pair  of  suspenders  for  the  dressing  and  prevents 
it  from  slipping  down.  The  circular  turns  should  be  further  pinned 
to  each  other. 

Describe  the  anterior  fi§^ure-of-eight  of  the  chest. 

This  requires  a  roller  about  seven  and  a  half  yards  long  and  two 
and  a  half  inches  wide. 

It  is  fixed  by  a  circular  turn  about  the  upper  portion  of  the  right 
arm.  The  bandage  is  then  carried  over  the  top  of  the  shoulder, 
across  the  chest,  beneath  the  axilla  of  the  left  side,  over  the  top  of 
the  shoulder  and  obliquely  downward  over  the  front  of  the  chest 
again  to  the  axilla  of  the  right  side  ;  up  behind  the  shoulder  and 
over  it,  obliquely  downward  to  the  opposite  axilla  ;  these  turns  are 
continued  until  as  many  as  are  required  have  been  applied. 

This  dressing  is  useful  for  ajDproximating  the  shoulders  and  for 
retaining  applications  to  the  front  of  the  chest. 

Describe  the  posterior  figure-of-eig^ht  of  the  chest. 

This  bandage  differs  from  the  anterior  figure-of-eight  only  in 
the  fact  that  it  is  started  by  a  repeated  circular  turn  about  the 
left  humerus,  as  near  the  axillary  folds  as  it  can  be  applied.  The 
roller  is  then  carried  upward  over  the  top  of  the  shoulder,  across 


ROLLER  BANDAGES  OF  THE  TRUNK. 


33 


tlie  back  to  the  riglit  axilla,  over  the  top  of  the  right  shoulder  and 
hack  again  across  the  back  to  the  left  axilla  ;  these  turns  being  re- 
peated, excepting  the  circular  one  about  the  arm,  and  as  many  being 
applied  as  are  required. 

This  dressing  is  sometimes  used  in  the  treatment  of  fractures  of 
the  clavicle,  or  may  be  emj^loyed  to  retain  applications  to  the  dorsal 
aspect  of  the  chest. 

Fig.  17. 


Spica  of  Breast. 

Describe  the  spica  of  the  breast. 

This  roller  may  be  single  or  double,  depending  upon  whether  one 
or  both  breasts  are  to  be  included. 

The  single  spica  of  the  breast  requires  a  roller  ten  yards  long  and 
two  and  one-half  inches  wide. 

The  initial  extremity  of  the  bandage  is  jB.xed  at  the  angle  of  the 
scapula  of  the  aifected  side  ;  the  bandage  is  carried  upward  to  the 
top  of  the  shoulder  on  the  sound  side,  over  this,  downward  across 
the  chest  so  that  the  upper  border  of  the  bandage  just  includes  the 
lower  limits  of  the  mammary  gland,  and  on  to  the  point  of  start- 
ing. This  turn  is  repeated  to  secure  the  initial  extremity  of  the 
roller.  When,  on  repeating  this  turn,  the  lower  border  of  the  breast 
is  reached,  the  bandage  is  carried,  circularly,  completely  around  the 


34  ESSEJ^TtALS  OF  BANDAGING}. 

cKest,  its  lower  border  Intersecting,  below  the  breast  and  sliglitly 
beyond  the  nipple  line,  the  first  oblique  turn.  It  is  then  con- 
tinued to  the  point  of  starting,  where  it  follows  the  course  of  the 
first  turn  over  the  top  of  the  sound  shoulder  and  down  beneath  the 
affected  breast,  overlapping  its  predecessor  for  two-thirds  of  its  width. 
Another  circular  turn  is  now  applied,  overlapping  upward  to  the 
same  extent.  These  turns  are  repeated,  alternating  the  oblique  over 
the  shoulder  with  the  circular  turns  about  the  chest,  till  the  breast 
is  completely  covered  in.  The  angles  formed  by  the  intersection  of 
these  turns  at  the  outer  side  of  the  breast  should  all  lie  in  a  straight 
line,  parallel  to  the  long  axis  of  the  body. 

The  double  spica  of  the  breast  requires  a  roller  fourteen  yards 
long  and  two  and  a  half  inches  wide.  Since  bandages  of  tliis  length 
are  difficult  to  manage  on  account  of  their  bulk,  it  is  customary  to 
use  two  bandages,  pinning  the  terminal  extremity  of  one,  after  it 
has  been  applied,  to  the  initial  extremity  of  the  other. 

This  bandage  is  started  by  placing  the  initial  extremity  of  the 
roller  at  the  angle  of  the  left  scapula  ;  the  bandage  is  carried  upward 
over  the  right  shoulder,  downward  under  the  left  breast  and  back  to 
the  point  of  starting  ;  this  turn  is  repeated,  for  the  purpose  of  fixing 
the  initial  extremity.  The  roller  is  then  carried  directly  across  the 
back  and  around  the  side  of  the  chest  till  it  passes  beneath  the  right 
nipple,  its  upper  margin  just  including  the  lower  border  of  the  mam- 
mary gland.  From  this  point  it  is  carried  obliquely  upward  across 
the  chest,  over  the  top  of  the  left  shoulder,  and  obliquely  down- 
ward over  the  back  and  toward  the  right  side  ;  a  circular  turn  is  then 
made  about  the  entire  chest,  after  which  another  oblique  turn  is 
formed,  passing  over  the  right  shoulder  and  under  the  left  breast, 
across  the  dorsal  aspect  of  the  thorax,  around  the  side  of  the  chest, 
under  the  right  breast,  upward  across  the  front  of  the  chest,  and 
over  the  top  of  the  left  shoulder,  after  which  a  second  circular  turn 
is  made.  Each  of  these  turns  overlaps  its  predecessor  for  two-thirds 
of  the  width  of  the  bandage. 

In  this  double  spica  of  the  breast  there  are  two  oblique  shoulder 
turns  for  each  circular  chest  turn,  the  left  breast  being  taken  in  by  a 
turn  passing  downward  from  the  right  shoulder,  the  right  breast  by 
a  turn  passing  upward  toward  the  left  shoulder,  before  the  bandage 
is  carried  completely  around  the  chest. 


ROLLER  BANDAGES  OF  LOWER  EXTREMITIES. 


35 


In  case  of  abscess,  or  swelling  of  the  breast,  this  bandage  is  some- 
times used.  It  enables  veiy  firm  pressure  to  be  ai)plied  to  this 
region. 

Describe  the  spica  of  the  foot. 

This  requires  a  roller  five  yards  long  and  two  and  a  half  inches  wide. 

It  is  started  by  a  repeated  circular  turn  about  the  ankle.     The 
roller  is  then  can-ied  across  the  dorsum  of  the  foot  to  the  metatarso- 
phalangeal articulation  of  the  great  toe ;  at  this  point  a  circular 
turn  is  made  about  the  foot,  and  to  this  is  added  a  spiral  turn, 
overlapping  the  circular  turn  upward  for  three-fourths  of  its  width  ; 
the  roller  is  then  carried  over  the  dorsum  of  the  foot,  along  its  lat- 

FlG.  18. 


Spica  of  the  Foot. 

eral  aspect,  and  around  the  back  of  the  heel,  so  that  the  lower  bor- 
der of  the  bandage  is  a  trifle  below  the  level  of  the  sole ;  the  roller 
is  carried  back  from  the  heel  along  the  side  of  the  foot,  and  over 
its  dorsum,  crossing  the  beginning  of  the  turn  which  passes  around 
the  heel  exactl}^  in  the  middle  line.  The  bandage  is  again  passed 
around  the  sole  of  the  foot,  across  its  dorsum,  along  the  side, 
around  the  back  of  heel,  and  back  again  to  the  dorsum,  intersect- 
ing the  beginning  of  the  second  heel  turn  at  this  point.  These 
turns  are  continued  till  the  whole  foot  is  completely  covered  in, 


36  ESSENTIALS   OF  BANDAGING. 

excepting  a  small  portion  of  the  sole  of  the  heel,  when  the  band- ' 
age  may  be  either  cut  and  pinned  at  the  ankle,  or  mRv  be  caiTJed 
up  the  leg.  The  spicas  or  angles  of  mtersection  of  the  turns  pass- 
ing across  the  dorsum  of  the  foot  should  all  lie  precisely  in  the  mid- 
dle line.  Each  of  these  figure-of-eight  turns  must  be.  through  its 
whole  extent,  parallel  to  its  predecessor,  and  must  overlap  for  three- 
fourths  of  the  width  of  the  bandage. 

Tliis  bandage  affords  a  ready  meaus  of  exerting  a  firm  pressure 
upuu  the  whijle  surface  of  the  foot. 

Describe  the  spiral  reversed  of  the  foot  covering  in  the  heel. 

This  requires  a  roller  four  yards  long  and  two  and  one-half  inches 
wide. 

The  bandage  is  fixed  bj'^  a  repeated  circular  turn  about  the  ankle  ;  it 
is  then  carried  obliquely  down  over  the  top  of  the  instep  and  a  circular 
tui-n  is  made  around  the  foot  at  the  level  of  the  metatarso-phalaugeal 
articulation  of  the  great  toe.  The  dorsum  of  the  foot  is  now  cov- 
ered in  by  three  spiral  reversed  turns,  each  overlapping  toward  the 

Fig.  19. 


Spiral  Eeveised  Covering  in  the  Heel. 

ankle  two-thirds  of  the  widtli  of  the  roller,  and  the  angle  of  reverses 
being  kept  in  the  middle  hue.  When  the  top  of  the  instep  is 
reached  the  bandage  is  earned  over  the  dorsum  of  the  foot,  around 
the  point  uf  the  heel,  back  to  the  dorsum  of  the  foot^  down  around 


ROLLER  BANDAGES   OF   LOWER  EXTREMITIES.  57 

the  sole  of  the  heel,  obliquely  upward  unci  backward  from  this  point 
behind  the  malleolus  and  around  the  back  of  the  heel,  forward  over 
the  malleolus,  over  the  top  of  the  instep,  downward  again  across 
the  sole  of  the  heel,  upward  and  backward  behind  the  malleolus, 
across  the  back  of  the  heel  and  across  the  malleolus  and  the  dorsum 
of  the  foot.  The  bandage  may  be  farther  secured  by  an  added 
circular  turn,  passing  from  the  top  of  the  instep  around  the  point 
of  the  heel.  It  is  terminated  by  one  or  two  turns  about  the  ankle. 
These  heel  turns  can  be  applied  by  remembering  that  the  bandage 

Fig.  20. 


Spiral  Reverjed  of  Lower  Extremity. 


goes  over  the  instep,  uuder  the  heel,  hach  of  the  heel,  the  words 
ore?',  under  and  bach  conveniently  summarizing  the  direction  in 
wliich  the  roller  should  be  carried. 

In  wounds  or  in  pathological  conditions  of  the  heel  this  bandage 
will  be  found  useful. 

Describe  the  spiral  reversed  of  the  lower  extremity. 

This  requires  a  roller  twelve  yards  long  and  two  and  one-half 
inches  wide. 

The  bandage  is  started  by  a  repeated  circular  turn  about  the 
ankle.     It  is  then  carried  obliquely  down  over  the  top  of  the  instep, 


38  ESSENTIALS   OF  BANDAGING. 

and  around  the  foot  at  tlie  level  of  tte  metatarso-phalangeal  articu- 
lation of  the  great  toe.  The  instep  is  covered  in  either  by  spica 
turns,  as  in  the  case  of  the  spica  of  the  foot,  or  by  spiral  reversed 
turns.  The  heel  is  left  exposed.  The  bandage  is  then  earned 
around  the  ankle  and  up  the  leg,  beginning  the  reverses  as  soon 
as  the  increasing  diameter  of  the  limb  requires  it.  The  knee  may 
be  covered  by  spiral  reversed  turns  or  by  the  figure-of-eight  of  the 
knee.  If  the  latter  is  employed  the  bandage  is  carried  upward 
across  the  popliteal  space,  around  the  front  of  the  thigh,  downward 
across  the  popliteal  space,  and  around  the  front  of  the  upper  portion 
of  the  leg,  overlapping  the  last  spiral  reversed  turn  for  two-thhds  of 
its  width.  The  roller  is  again  carried  across  the  popliteal  space  and 
around  the  thigh,  overlapping  downward  the  previous  turn  in  this 
region  for  two-thirds  of  its  width.  It  is  now  carried  down  again  and 
around  the  leg,  overlapping  toward  the  patella.  These  turns  are 
continued,  both  the  upper  and  lower  overlapping  toward  the  patella, 
till  the  descending  and  ascending  turns  almost  meet,  when  the 
remaining  space  is  covered  in  by  a  circular  turn  passing  directly 
across  the  centre  of  the  patella.  The  bandage  is  now  continued  up 
the  thigh  by  spiral  reversed  turns  until  the  groin  is  reached.  It  may 
be  pinned  at  this  point,  or  further  secured  by  one  or  two  spica  turns 
of  the  groin. 

Describe  the  spica  of  the  groin. 

Tlie  spica  of  the  groin  may  be  either  shigh  or  douUe,  depending 
upon  whether  one  or  both  groins  are  included  in  the  dressing; 
farther,  it  may  be  either  ascending  or  descending,  depending  upon 
whether  the  overlapping  is  from  below  upward  or  in  the  reverse 
direction. 

The  single  ascending  spica  of  the  groin  requires  a  roller  ten  yards 
long  and  two  and  a  half  or  three  inches  wide. 

The  bandage  is  fixed  by  a  repeated  circular  turn  apphed  as  close 
to  the  ilco-femoral  fold  as  possible.  If  the  right  side  is  being  dressed 
the  bandage  is  then  carried  obliquely  across  the  pubes,  around  the 
body  beneath  the  ihac  crest  of  each  side,  and  down  across  the  right 
thigh,  intersecting  the  beginning  of  the  body  turn  and  forming  the 
first  angle  or  spica,  which  should  be  placed  slightly  to  the  inner  side 
of  the  middle  hne  of  the  anterior  surface  of  the  thigh.     The  band- 


ROLLER  BANDAGES   OF  LOWER  EXTREMITIES. 


39 


age  is  then  carried  around  back  of  the  thigh,  forward  across  the 
front,  overlapping  the  first  turn  for  two-thirds  of  its  width,  around 
the  body  and  back  again  across  the  thigh,  making  the  second  angle 
of  crossing.  These  turns  are  repeated,  overlapping  upward  till  a 
sufficient  surface  is  covered  in.  The  bandage  may  be  secured  by  a 
circular  turn  around  the  waist. 

2^ke  dtaceading  spica  of  the  groin  is  similar  in  its  turns  to  the 

Fig.  21. 


Single  AsceDding*Spiea  of  the  Groin. 


ascending,  excepting  in  the  fact  that  the  first  intersection  or  cross- 
ing of  the  bandage  is  carried  far  above  the  circular  turn  around 
the  thigh,  in  place  of  overlapping  it.  This  is  accomplished  by 
carrying  the  bandage,  after  the  double-thigh  turn  has  been  made 
to  fix  it,  across  the  front  of  the  belly  some  distance  above  the  pubes, 
and  around  the  body  above  the  crest  of  the  ileum.  Each  succeeding 
turn  overlaps  downward  until  the  last  spica  overlaps  the  circular  turn 
about  the  thigh. 


40  ESSENTIALS  OF  BANDAGING. 

The  double  spica  of  the  groin  requires  a  bandage  fourteen  yards 
long  and  two  and  one-half  inches  wide .  It  is  fixed  by  a  circular  turn 
around  the  waist  once  rej^eated  ;  the  roller  is  then  carried  obliquely 
downward  across  the  belly,  across  the  fold  of  the  left  groin,  around 
the  back  of  the  left  thigh,  forward  and  upward  jDarallel  to  Poupart's 
ligament,  forming  the  first  intersection  with  the  turn  passing  down- 
ward, around  the  back,  downward  parallel  to  the  right  Poupart's 
ligament,  around  the  back  of  this  thigh,  upward  and  across  Poupart's 
ligament,  forming  the  second  intersection,  and  across  the  belly,  form- 
ing with  the  first  oblique  abdominal  turn  the  third  intersection. 
These  turns  are  repeated,  being  carried  around  the  back,  around  the 
left  thigh,  aroucd  the  back,  around  the  right  thigh,  around  the 
back,  and  so  on  until  the  required  surface  is  covered  in.  The 
bandage  may  overlap  upward  or  downward,  forming  either  the 
ascending  or  the  descending  double  spica  of  the  groin. 


HEAD  BANDAGES» 

Describe  the  Barton  bandage. 

This  requires  a  bandage  five  yards  long  and  two  inches  wide. 

The  dresser,  standing  in  front  of  the  patient,  places  the  initial 
extremity  of  the  roller  directly  behind  the  left  ear ;  the  body  of  the 
bandage  is  carried  downward  under  the  occiput,  and  upward  behind 
the  right  ear,  then  directly  across  the  top  of  the  head  from  the  right 
to  the  left  side,  downward  in  front  of  the  left  ear,  under  the  chin, 
upward  in  front  of  the  right  ear,  and  across  the  top  of  the  head,  from 
the  left  to  the  right  side,  to  the  point  of  starting  ;  thence  across  the 
junction  of  the  occiput  and  back  of  the  neck,  directly  forward  under 
the  ear,  along  the  ramus  of  the  lower  jaw,  around  the  symphysis  or 


HEAD  BANDAGES.  41 

front  of  thechin,  back  again  along  the  ramus  of  the  lower  jaw,  and 
beneath  the  left  ear  to  the  upper  portion  of  the  back  of  the  neck. 
From  this  point  the  bandage  is  carried  upward  behind  the  right  ear 
across  the  top  of  the  head,  and  is  continued  exactly  as  were  the 
first  turns.     These  turns  are  repeated  three  times. 

Note  that  each  succeeding  turn  overlies  and  does  not  overlap  its 
predecessor,  and  that  the  angle  made  by  the  crossing  of  the  bandage 


Fig.  22. 


Barton's  Bandage. 

on  top  of  the  head,  must  be  exactly  in  the  middle  line,  and  its 
anterior  margin  must  lie  about  two  inches  posterior  to  the  junction 
of  the  scalp  and  forehead.  All  the  intersections  of  this  bandage  are 
pinned.  It  may  be  made  still  more  secure  by  cariying  an  additional 
circular  turn  from  the  occiput  around  the  forehead. 

This  dressing  is  useful  in  the  treatment  of  fractures  of  the  jaw. 
It  is  also  of  service  when  tight  pressure  is  required  at  any  portion  of 
the  surface  covered  by  it. 

Describe  the  Gibson  bandage. 

This  requires  a  roller  five  yards  long  and  two  inches  wide. 


42  ESSENTIALS  OF  BANDAGING. 

The  initial  extremity  is  placed  upon  the  top  of  the  head,  and  the 
roller  is  carried  downward  in  front  of  one  ear,  under  the  chin, 
upward  in  front  of  the  other  ear,  and  on  to  the  point  of  starting. 
This  turn  is  twice  repeated,  when  the  bandage  is  reversed  in  the  tem- 
]wral  region  above  the  ear,  and  carried  around  the  head  three  times, 
including  the  forehead,  the  temporal  regions  and  the  occiput:  on 

Fig.  23. 


Gibson's  Bandage. 

the  completion  of  the  third  turn  the  bandage  is  carried  obliquely- 
downward  behind  the  ear  to  the  back  of  the  neck,  forward  along  the 
ramus  of  the  jaw,  around  the  front  of  the  chin,  and  backward  along 
the  opposite  side  of  the  jaAV  to  the  back  of  the  neck  ;  this  turn  is 
repeated  three  times.  The  bandage  is  then  completed  by  reversing 
it  in  the  posterior  middle  neck  line,  and  carrying  it  directly  forward 
to  the  frontal  part  of  the  circular  occipito-frontal  turn.  All  the  inter- 
sections are  pinned. 

In  applying  this  bandage  each  turn  overlies  its  predecessor,  and 
does  not  overlap.  The  difficult  part  of  the  dressing  is  the  proper 
securing  of  the  first  vertical  turns.     Where  the  head  slopes  forward 


HEAD   BANDAGES.  43 

from  the  vertex,  these  are  liable  to  slip  foi-ward  ;  they  should  always 
be  passed  over  the  top  of  the  head  as  far  back  as  possible. 

This  dressing  is  applicable  to  the  treatment  of  fractures  of  the 
jaw,  but  is  not  so  satisfactory  as  the  Barton  bandage. 

Describe  the  oblique  of  the  jaw. 

This  requires  a  bandage  five  yards  long  and  two  inches  wide. 

Fig.  24. 


Oblique  Bandage  of  the  Jav7. 

Facing  the  patient  the  dresser  starts  the  bandage  by  placing  its  initial 
extremity  upon  the  forehead,  and  carrying  the  body  of  the  roller 
toward  the  injured  side  and  circularly  around  the  head.  This  fronto- 
occipital  turn  is  repeated  to  fix  the  bandage.  It  is  then  carried  above 
the  ear  of  the  injured  side,  obliciuely  downward  behind  it  to  the 
back  of  the  neck,  around  the  front  of  the  neck  to  the  angle  of  the 
jaw  of  the  aff"ected  side,  thence  upward  in  front  of  the  ear,  directly 
across  the  top  of  the  head,  downward  behind  the  ear  of  the  oj^posite 
side,  around  under  the  chin,  upward  again  in  front  of  the  ear  of  the 
injui'ed  side,  overlapping  forward  for  three-quarters  of  the  width  of 
the  bandage,  across  the  top  of  the  head,  downward  behind  the  oppo- 
site ear,  and  so  continued  untU  a  sufficient  number  of  turns  have  been 
applied,  when  the  bandage  may  be  made  still  more  secure  by  revers- 


44  ESSENTIALS   OF  BANDAGING. 

ing  above  the  ear  and  adding  a  circular  turn  including  the  occiput 
and  forehead.     All  intersections  are  pinned. 

This  dressing  is  of  service  in  the  treatment  of  injuries  and 
wounds  of  the  parotid  region.  It  is  commonl}'  advised  in  the  dress- 
ing of  fractures  involving  the  neck  of  the  condyle  of  the  lower  jaw. 
It  is,  however,  difficult  to  understand  how  it  can  be  of  special  ser- 
vice when  applied  to  this  form  of  injury. 

Fig.  25. 


Recurrent  of  Scalp. 

Describe  the  recurrent  of  the  scalp. 

This  bandage  should  be  seven  yards  long  and  two  inches  wide. 
It  is  fixed  by  repeated  circular  turns  around  the  forehead  and  occi- 
put. At  the  middle  of  the  forehead  the  roller  is  reversed,  is  secured 
by  the  thumb  of  the  dresser  or  an  assistant,  and  is  carried  directly 
back  across  the  top  of  the  head  until  it  reaches  the  lower  border  of 
the  occipital  turn  ;  here  it  is  again  reversed,  the  reverse  is  secured  by 
an  assistant,  and  the  bandage  is  carried  directly  forward,  overlapping 
the  preceding  turn  for  three-quarters  of  its  width  ;  having  reached 
the  frontal  portion  of  the  circular  turn,  it  is  caught  by  the  thumb 
again  and  carried  directly  backward.  The  bandage  is  carried  to 
and  fro  in  this  way  until  half  the  scalp  is  covered  in,  when  these 
loopings  are  fixed  by  a  circular  turn.     The  bandage  is  again  reversed 


HEAD  BANDAGES.  45 

at  tlie  forehead  and  the  other  side  of  the  scalp  is  included  in  a  simi- 
lar manner.  The  dressing  is  completed  by  a  repeated  circular  turn, 
pins  being  applied  to  further  secure  the  loops  of  the  reverses. 
These  reversed  turns  should  converge  in  front  and  behind  to  the  cen- 
tral points  of  the  forehead  and  occiput. 

This  bandage  is  of  service  in  retaining  dressings  to  the  upper  part 
of  the  scaljD.  In  applying  it  care  must  be  taken  that  the  circular 
turn  passes  from  the  forehead  around  the  head  beneath  the  supenor 
curved  line  of  the  occiput;  there  is  then  no  tendency  for  the  dressing 
to  slip  off,  since  before  it  can  be  removed  the  circular  turn  must  pass 
over  a  greater  diameter  than  it  already  embraces. 

Describe  the  figure-of-eight  of  the  eye. 

This  bandage  may  be  either  single  or  double,  depending  upon 
whether  one  or  both  eyes  are  included.  The  initial  extremity  of  the 
roller  is  placed  at  the  middle  of  the  forehead  and  the  bandage  is 
carried  away  from  the  injured  eye,  making  a  repeated  fronto-occipi- 
tal  circular  turn  ;  on  the  third  turn  the  bandage  is  carried  downward 
behind  the  ear  of  the  sound  side,  around  the  back  of  the  neck  just 
under  the  occiput,  forward  and  ujoward  under  the  ear  of  the 
affected  side,  obliquely  across  the  eye,  around  the  side  of  the  head, 
thence  downward  around  the  back  of  the  occiput,  under  the  ear  of 
the  affected  side,  upward  across  the  eye,  overlapping  for  two-thirds 
of  the  width  of  the  bandage  either  upward  or  downward  as  may  be 
required.  These  oblique  turns  are  repeated  until  the  eye  is  com- 
pletely covered  in ;  more  than  two  or  three  are  rarely  required. 
The  bandage  is  then  completed  by  a  fronto-occipital  turn  and  all 
intersections  are  pinned.  For  neat  bandaging  each  oblique  turn  may 
be  alternated  with  a  circular  one,  both  sets  of  turns  overlapping  and 
forming  a  series  of  angles  in  the  middleline. 

The  double  Jig ure-of -eight  of  the  eye  requires  a  bandage  seven 
yards  long  and  two  inches  wide  ;  each  eye  may  be  covered  in  inde- 
pendently by  the  turns  employed  in  the  single  bandage.  In  this 
case,  after  one  eye  is  completely  covered,  the  bandage  is  carried  by 
a  circular  turn  to  the  forehead,  and  is  then  continued  downward 
across  the  other  eye  and  under  the  ear,  upward  over  the  parietal 
eminence,  again  across  the  eye  and  so  continued  till  a  sufficient  num- 
ber of  turns  are  applied,  when  the  dressing  is  completed  by  a  cir- 


46 


ESSENTIALS  OF  BANDAGING. 


culnr  turn ;  or  tlie  bandage  having  been  fixed  by  a  repeated  circular 
turn  as  in  the  single  figure-of-eiglit,  is  carried  under  the  ear  and 
over  the  ej^e  as  before,  then  around  the  occiput,  forward  over  the 
ear,  obliquely  downward  over  the  opposite  eye,  thence  under  the  ear, 
around  the  back  of  the  neck,  under  the  opposite  ear,  obliquely  up- 
ward over  the  eye,  around  the  occiput  again,  forward  and  downward 
across  the  opposite  eye  and  so  continued,  forming  two  or  three 
angles  of  intersection  in  line  with  the  bridge  of  the  nose  and  over- 

FlG.  26. 


Figure-of- Eight  of  Both  Eyes. 


lapping  regularly  upward.  The  dressing  may  be  secured  bj''  one  or 
two  circular  front o-occipital  turns. 

The  applications  of  this  bandage  are  obvious. 

As  a  matter  of  clinical  experience  it  is  found  best  to  employ  thin 
flannel  cut  bias  for  these  bandages,  since  otherwise  undue  pressure 
may  be  exerted.  The  comfort  of  the  patient  will  be  further  con- 
sulted by  placing  small  iDads  of  cotton  in  and  behind  each  auricle 
and  passing  the  bandage  directly  over  these  organs,  in  place  of  making 
an  effort  to  leave  them  free 


HEAD  BANDAGES.  47 

^Describe  the  occipito-facial  bandag-e. 

This  requires  a  roller  four  j^arcls  long  and  two  inches  wide. 

The  initial  extremity  of  the  bandage  is  placed  upon  the  crown  of 
the  head,  or,  if  the  latter  does  not  slope  abruptly  forward,  two  inches 
anterior  to  this  point ;  the  roller  is  then  carried  downward  under  the 
chin  and  upward  to  the  point  of  starting  ;  this  turn  is  repeated  twice ; 
the  bandage  is  then  reversed  just  above  the  position  of  the  ear,  and 
three  circular  turns  are  made  embracing  the  occiput  and  forehead  ; 
the  intersections  are  pinned. 


Fig.  27. 


Recurrent  Bandage  of  Stump. 

This  bandage  may  be  employed  to  make  pressure  in  the  submental 
region,  or  upon  any  part  of  the  scalp  covered  by  it. 

Describe  the  fronto-oecipito-cervical  figure-of-eight. 

This  requires  a  bandage  three  yards  long  and  two  inches  wide. 

It  is  fixed  by  a  repeated  fronto-occipital  turn  placed  just  above  the 
ear,  the  bandage  is  then  carried  obliquely  downward  behind  the  ear, 
across  the  back  of  the  neck,  forward  around  tbe  front  of  the  neck,  to 
the  back  of  the  neck  again,  obliquely  upward  above  the  opposite  ear, 


48  fiSSENTiALS   OF  BANDAGING. 

across  tlie  forehead,  downward  behind  the  ear  again  and  around  the 
neck,  and  is  so  continued  till  three  complete  turns  are  made,  when 
it  is  pinned  at  any  convenient  point. 

This  bandage  is  useful  in  retaining  dressings  to  the  back  of  the 
neck. 

Describe  the  fronto-occipito-mental  figure-of-eight. 

This  requires  the  same  length  of  bandage  as  the  preceding,  and  is 
apjilied  in  exactly  the  same  way,  except  in  place  of  carrying  a  turn 
around  the  neck  it  is  carried  around  the  front  of  the  chin.  This 
enables  the  dresser  to  applj^  much  more  pressure  than  is  possible  in 
the  preceding  bandage. 

Describe  the  recurrent  bandage  for  a  stump. 

This  requires  a  roller  five  yards  long  and  two  inches  wide.  It  is 
fixed  by  a  repeated  circular  turn  around  the  limb  three  or  four 
inches  above  the  stump.  The  roher  is  then  reversed,  being  secured 
by  the  thumb  of  the  left  hand,  carried  over  the  middle  of  the 
stump,  and  caught  underneath  by  the  fore-finger  of  the  left  hand. 
The  bandage  is  again  reversed  and  brought  up  over  the  stump  so 
that  it  overlaps  the  preceding  turn  by  an  inch  and  a  half  at  the 
middle  of  the  stump,  but  conveys  again  to  the  starting  point 
secured  by  the  thumb.  These  loops  are  repeated  and  secured  in 
turn  by  the  thumb  and  forefinger,  until  the  end  is  covered  in,  when 
tlie  loopings  are  fixed  by  circular  and  spiral  reversed  turns  around 
the  limb.  As  it  is  often  difficult  to  prevent  this  bandage  from  slip- 
ping off  a  conical  stump,  it  may  be  further  secured  by  strips  of 
adhesive  plaster. 

Describe  the  T  bandage. 

Two  strips  of  bandage,  each  four  feet  long  and  three  inches  in 
width,  are  required ;  to  the  middle  of  one  strip,  and  passing  at  right 
angles  to  it,  one  extremity  of  the  other  strip  is  pinned  or  sewed. 

This  bandage  is  of  use  in  retaining  dressings  to  the  rectum  or 
perineum.  Tlie  horizontal  limb  is  secured  around  the  waist,  the 
vertical  limb  is  carried  down  along  the  perineum  and  is  brought  for- 
ward. It  is  then  split  down  to  the  scroto-perineal  junction,  and  the 
two  ends  are  carried  upward  and  forward,  one  to  each  side,  and  are 
secured  to  the  circular  turn  around  the  body. 


HEAD  BANDAGES.  49 

Describe  the  many-tailed  bandage. 

This  was  originally  called  the  bandage  of  Scultetus,  and  consisted 
of  a  number  of  short  pieces  of  bandage,  often  as  many  as  18  or  20, 
each  placed  parallel  to  its  predecessor  and  overlapping  for  two-thirds 
of  its  width.  These  pieces  were  secured  in  their  relative  positions 
by  being  stitched  to  another  piece  passed  vertically  along  their 
middle.  If  a  limb  were  to  be  bandaged,  all  of  the  imbricated  pieces 
could  be  slipped  under  at  once  ;  the  limb  could  then  be  allowed  to 
rest  upon  the  bed  and  the  jDieces  could  be  folded  over,  commencing 
at  one  end  and  folding  over  in  turn  each  extremity  of  every  piece, 
l^assing  upward.  In  this  form  the  bandage  is  now  rarely  used,  since 
frequent  dressing  of  parts  which  cannot  be  readily  moved  is  not  so 
often  required. 

The  many-tailed  bandage  commonly  used  is  made  of  a  piece  of 
flannel  or  musHn  from  six  to  eight  inches  in  width,  and  of  sufficient 
length  to  go  one  and  one-half  times  around  the  part  to  be  bandaged. 
The  strip  is  torn  from  each  extremity  toward  the  middle  for  about 
one-third  of  its  length  ;  two  or  three  tears  are  made  in  such  a  way 
that  the  extremities  are  divided  into  three  or  four  pieces  of  equal 
width. 

This  bandage  is  very  useful  in  making  pressure  and  in  retaining 
dressings  after  laparotomy. 

Describe  the  four-tailed  bandage. 

This  requires  a  piece  of  muslin  from  four  to  twelve  inches  in  width 
and  from  eighteen  to  twenty-four  inches  in  length.  It  is  torn  down 
the  centre  from  each  end  to  within  from  two  to  six  inches  of  its 
middle. 

This  bandage  is  sometimes  used  in  the  treatment  of  fractures  of 
the  lower  jaw  or  in  fractures  of  the  clavicle. 

Describe  the  crossed  bandage  of  the  perineum. 

This  requires  a  bandage  seven  yards  long  and  two  and  a  half  to 
three  inches  wide. 

It  is  fixed  by  a  circular  body  turn  around  the  pelvis,  placed  be- 
neath the  iliac  crests.  It  is  then  carried  downward  along  the  right 
groin,  across  the  perineum,  around  the  back  of  the  left  thigh  at  the 
position  of  the  ilio-femoral  fold,  upward  above  the  trochanter  and 
4 


50  ESSENTIALS  OF  BAIs"DAGING. 

below  the  crest  of  the  ileum,  completely  around  the  body  until  it  is 
just  above  the  left  trochanter,  down  along  the  left  groin,  across  the 
perineum,  around  the  back  of  the  right  thigh  at  the  ilio-femoral  fold, 
upward  and  foi^ward  just  above  the  right  trochanter,  and  is  continued 
by  repeating  these  turns  till  a  firm  dressing  is  formed. 

This  bandage  is  useful  for  retaining  dressings  to  the  scrotal  and 
perineal  regions. 

Describe  the  figure-of-eight  bandage  of  the  lower  extremity. 

Tliis  requires  a  bandage  2}  inches  wide  and  12  j-ards  long ;  the 
bandage  is  fixed  by  a  repeated  turn  around  the  ankle ;  it  is  then 
carried  across  the  instep,  around  the  foot,  and  up  to  the  ankle  by  one  or 
two  reversed  tui"ns.  It  is  carried  around  the  ankle  again  and  up  the 
leg  by  one  or  two  spiral  turns  overlapping  for  two-thii'ds  of  the  width 
of  the  bandage.  The  roller  is  then  continued  by  an  oblique  turn  to 
that  portion  of  the  leg  just  below  the  knee  joint  where  the  calf 
grows  smaller  ;  it  is  earned  around  the  leg  at  this  point  and  continued 
obhquely  downward  again  until  it  overlaps  the  spiral  turns  above  the 
ankle.  It  is  brought  around  the  back  of  the  leg  and  earned  oblique- 
ly upward,  catching  again  upon  the  lesser  diameter  above  the  calf ;  it 
is  then  continued  downward,  overlapping  the  preceding  turn  upward. 
These  turns  are  repeated  until  the  whole  leg  is  covered  in. 

This  bandage  is  exceedingly  useful,  from  the  fact  that  it  remains 
indefinitely  upon  a  muscular  calf,  even  though  the  patient  be  active 
upon  his  feet. 


HANDKERCHIEF  BANDAGES  FOR  THE  HEAD.        51 


HANDKERCHIEF  BANDAGES. 


Describe  the  handkerchief  bandage. 

This  requires  muslin,  calico,  or  any  thin,  strong,  soft  fabric  cut  in 
the  form  of  either  a  square  or  a  triangle.  The  square  should 
measure  thirty-two  inches. 

The  triangle  is  made  by  dividing  this  square  obliquely  across  from 
angle  to  angle,  or  by  simply  folding  the  square  in  the  form  of  a  tri- 
angle. The  parts  of  the  triangle  are  the  hase^  the  apex  (the  angle 
opposite  the  base),  and  the  angles  or  ends. 

Tlie  cravat  is  formed  by  folding  the  apex  in  toward  the  base  and 
repeating  the  folding  till  a  bandage  about  two  inches  in  width  is 
formed. 

The  names  of  the  handkerchief  bandages  have  been  devised  with 
the  idea  of  indicating  their  method  of  application  ;  the  first  name 
is  that  of  the  part  to  which  the  base  of  the  triangle  is  appHed, 
the  second  name  is  that  of  the  part  around  which  the  ends  are  car- 
ried. Thus  the  occipito-frontal  triangle  would  imply  that  the  base 
of  the  bandage  is  applied  to  the  occiput  and  that  the  ends  are  car- 
ried around  the  forehead. 


Handkerchief  Bandages  of  the  Head. 

How  is  the  occipito-frontal  triangle  applied? 

Apply  the  base  to  the  occiput,  letting  the  apex  fall  over  the  fore- 
head.   Carry  the  two  ends  forward  around  the  head  and  tie  in  front, 


52 


ESSENTIALS  OF  BANBAGlNa. 


or  cross,  and  pin  at  the  sides.     Turn  tlie  apex  up  and  pin  to  the  body 
of  the  bandage. 

How  is  the  fronto-occipital  triangle  applied? 

As  the  preceding,  except  that  the  base  is  apphed  to  the  forehead, 
and  the  ai)ex  falls  over  the  occiput. 

How  is  the  bi-temporal  triangle  applied  ? 

As  the  preceding,  except  that  the  base  is  applied  over  one  temple, 
the  apex  falls  over  the  other. 

In  the  choice  of  these  three  bandages,  the  base  is  applied  over 
the  seat  of  injury,  or  where  most  pressure  is  desired. 


Fig.  28. 


Fig.  29. 


Beginning  of  Square  Cap  of  Head. 


Square  Cap  of  Head  Completed. 


How  is  the  vertieo-mental  triangle  applied  ? 

Apply  the  base  to  the  vertex  with  apex  back ;  carry  the  ends 
down  under  the  chin,  and  either  tie,  or  cross  and  pin.  Bring  the 
apex  to  one  side  and  pin. 

How  is  the  auriculo-occipital  triangle  applied  ? 

This  does  not  conform  to  the  rule  in  naming.  Place  the  base  in 
front  of  the  ear,  apex  back,  carry  one  end  under  the  chin,  the  other 
over  the  top  of  the  head  and  tie  or  pin  in  front  of  the  ear  on  the 
sound  side. 

How  is  the  square  cap  applied  ? 

Fold  the  handkerchief  so  that  a  quadrilateral  is  formed,  with  one 


HANDKERCHIEF  BANDAGES  OF  THE  TRUNK.  53 

border  overlappiDg  the  otlier  three  inches.  Apply  this  quadrilateral 
to  the  scalp,  with  the  projecting  border  next  the  surface  and  hang- 
ing over  the  eyes.  Bring  the  ends  of  the  short  fold  under  the  chin 
and  tie.  Fold  back  the  long  border  exposing  the  forehead,  pull 
the  ends  forward  till  the  bandage  fits  about  the  head,  then  carry 
them  back  and  tie  beneath  the  occiput. 

How  is  the  fronto-occipito-labialis  cravat  applied  ? 

Fold  the  triangle  into  a  cravat.  Place  the  body  upon  the  fore- 
head, carry  the  ends  back,  cross  at  the  back  of  the  neck,  and  bring 
them  forward,  tj^ing  or  pinning  over  the  upper  or  lower  lip,  as 
required  by  the  injury.  Used  to  approximate  lip  wounds,  and  to 
check  bleeding  from  the  coronary  arteries. 

How  is  the  occipito-sternal  triang^le  (compound)  applied  ? 

Apply  a  sterno-dorsal  (straight  around)  cravat  about  the  chest. 
Flex  the  head  upon  the  chest  and  apply  the  base  of  a  triangle,  apex 
foi-ward,  to  the  occiput,  caiTy  the  two  ends  down  to  the  sterno-dorsal 
cravat  and  secure.  The  apex  of  the  triangles  may  be  folded  back 
and  pinned.     Used  in  cut -throat  wounds  of  the  neck. 

How  is  the  parieto-axillaris  triangle  (compound)  applied? 

Apply  an  axillo-acromial  cravat  (around  the  shoulder).  Place  the 
base  of  a  triangle  over  the  parietal  eminence  of  the  opposite  side, 
cany  the  ends  around  the  head  and  cross  them  ;  incline  the  head 
laterally,  and  secure  the  ends  of  the  triangle  to  the  shoulder  cravat. 

Used  to  approximate  the  lips  of  wounds  at  the  side  of  the  neck. 


Handkerchief  Bandages  of  the  Trunk. 

How  is  the  axillo-cervical  cravat  applied  ? 

Place  the  body  of  the  cravat  in  the  axilla,  carry  the  ends  over  the 
shoulder,  across  each  other,  and  around  the  neck. 

Used  to  retain  dressings  in  the  axilla. 

How  is  the  bis-axillary  cravat  (simple)  applied  ? 

Place  the  body  in  the  axilla,  cross  the  ends  over  the  shoulder  and 
carry  one  across  the  chest,  the  other  across  the  back,  to  the  axilla 
of  the  opposite  side,  where  they  are  tied  or  pinned. 

Used  as  the  preceding  bandage. 


54  ESSENTIALS  OF  BANDAGING. 

How  is  the  bis-axillary  cravat  (compound)  applied  ? 

Place  the  body  of  one  cravat  in  the  axilla,  carry  its  ends  over  the 
shoulder  and  tie  (axillo-acromial  cravat).  Place  the  body  of  another 
cravat  in  the  opposite  axilla,  and  carry  the  ends  obliquely  across  the 
chest  and  back  to  the  first  cravat,  tying  them  together  when  one 
end  has  passed  through  the  loop  of  the  first  cravat. 

Used  to  retain  dressings  in  both  axillae. 

How  is  the  bis-axillo-scapulary  cravat  (simple)  applied  ? 

Place  the  body  to  the  front  of  the  shoulder,  with  the  lower  end 
one-third  longer  than  the  upper.     Carry  the  upper  end  over  the 

Fig.  30. 


Bis-axillo-scapulary  Cravat  (Compound). 

shoulder,  the  lower  end  under  the  axilla ;  continue  the  long  end 
obliquely  across  the  back  to  the  opposite  shoulder,  around  it,  and 
back  to  the  short  end,  to  which  it  is  tied.  This  forms  a  posterior 
figure-of-eight,  and  is  used  as  a  temporary  dressing  for  fractured 
clavicle. 

How  is  the  bis-axillo-scapulary  cravat  (compound)  applied  ? 

Loop  one  cravat  loosely  about  the  shoulder,  and  tie.  Place  the 
body  of  the  other  cravat  in  front  of  the  opposite  shoulder,  carry  the 
ends  back,  one  over  the  shoulder,  the  other  beneath  the  axilla. 
Tie  in  a  single  loose  knot,  carry  one  end  through  the  loop  of  the 
first  cravat,  and  tie  in  a  double  knot. 


HANDKERCHIEF   BANDAGES   OF  THE  TRUNK. 


55 


Used  to  draw  the  shoulders  forcibly  back,  as  in  fracture  of  the 
clavicle. 

How  is  the  dorso-bis-axillary  triangle  (compound)  applied? 

Breakfast  shawl.  Carry  a  cravat  around  the  chest  and  tie  in  front 
(dorso-sternal).  Place  the  base  of  a  triangle,  apex  down,  on  the 
back  of  the  neck,  carry  each  end  over  the  corresponding  shoulder, 
and  tie  to  the  dorso-sternal  cravat  in  front.  The  apex  is  fastened 
around  the  body  of  the  cravat  behind. 

Used  to  retain  dressings  to  the  shoulder  or  back. 

How  is  the  mammary  triangle  applied  ? 

Place  the  base  of  the  triangle  under  the  breast,  and  its  apex  over 


Fig.  31. 


Fig.  32. 


Mammary  Triangle. 


Gluteal  Triangle. 


the  shoulder  of  the  same  side.     Carry  one  end  across  the  opposite 
side  of  the  neck,  the  other  under  the  axilla  of  the  affected  side.    Tie 
at  the  back,  and  secure  the  apex  beneath  the  knot. 
Used  to  support  the  breast,  to  make  pressure,  to  retain  dressings. 

How  is  the  scroto-lumbar  triangle,  or  suspensory,  applied? 

Tie  a  cravat  about  the  waist.     Place  the  base  of  a  triangle  beneath 
the  scrotum,  carry  the  two  ends  up  and  secure  them  to  the  cravat. 
Finally  secure  the  apex  by  carrying  it  under  the  cravat,  folding  it 
in  front,  and  pinning. 
:    Used  as  a  suspensory  of  the  scrotum. 


56  ESSENTIALS  OF  BANDAGING. 

How  is  the  abdomino-ing-uinal  (simple)  handkerchief  bandage 
applied  ? 

For  this  bandage  one  long  cravat  may  be  made  by  tying  two 
together.  Place  the  body  of  the  cravat  back  of  the  thigh  in  such  a 
manner  that  one  end  may  be  two-thirds  longer  than  the  other. 
Bring  the  ends  to  the  front,  cross  over  the  groin,  and  carry  them 
around  opposite  sides  of  the  body,  knotting  or  pinning  in  front. 

Used  as  a  spica  of  the  groin,  to  retain  dressings  on  buboes,  or  to 
make  pressure  upon  them. 

How   is  the  abdomino-inguinal  (compound)  handkerchief 
bandage  applied  ? 

Place  the  centre  of  the  cravat  (three,  knotted  or  sewed  together) 
over  the  lumbar  vertebrae,  carry  the  two  ends  forward  on  each  side 
just  below  the  iliac  crests,  obliquely  downward  and  inward  over  the 
front  of  the  groins,  backward  between  the  thighs,  outward  around 
each  thigh  to  the  front ;  cross  over  the  pubes  and  pin  to  the  body 
of  the  cravat. 

How  is  the  gluteal  triangle  (compound)  applied  ? 

Tie  a  cravat  about  the  waist.  Place  the  base  of  a  triangle  ob- 
liquely at  the  gluteal  fold,  and  tie  the  ends  around  the  thigh.  Carry 
the  apex  up  and  under  the  cravat,  fold  it  over,  and  pin. 

Used  to  retain  dressings  to  the  gluteal  region. 


Handkerchief  Bandages  of  the  Extremities. 

How  is  the  palmar  triangle  applied  ? 

Place  the  base  of  the  triangle  on  either  the  palmar  or  dorsal  sur- 
face of  the  wrist,  fold  the  apex  over  the  hand  and  back  to  the  wrist, 
carry  the  ends  around  the  wrist  and  apex  and  tie  ;  fold  the  apex  back, 
and  pin  to  the  body  of  the  bandage. 
How  is  the  triangular  cap  of  the  shoulder  applied  ? 

1.  Place  the  base  on  the  shoulder,  apex  hanging  down  over  the 
arm  ;  carry  the  ends  under  the  axilla,  across  each  other,  around  the 
arm,  taking  in  the  apex,  and  tie.  Fold  the  apex  upward,  and  pin 
to  the  body  of  the  bandage. 

2.  Place  the  base  of  the  bandage  on  the  upper  part  of  the  arm, 
with  the  apex  covering  the  shoulder  ;  carry  the  ends  around  the  arm, 


HANDKERCHIEF  BANDAGES   OF  THE  EXTREMITIES. 


57 


across  each  other  in  the  axilla,  and  up  around  the  shoulder,  taking 
in  the  apex.  Fold  the  apex  down  and  pin.  Used  to  retain  dressings 
to  the  upper  part  of  the  arm  or  shoulder. 

How  is  the  triangular  cap  of  a  stump  applied? 

Place  the  base  under  the  stump,  carry  the  apex  over  its  end. 
Secure  the  apex  by  carrying  the  ends  around  the  limb,  and  pinning 
or  knotting.  Fold  the  apex  up,  and  pin  to  the  body  of  the 
bandage. 

How  is  the  cervico-brachial  triangle  applied? 

Sling  of  the  arm.  Place  the  base  of  a  triangle  at  the  wrist  of 
the  flexed  forearm,  carry  the  ends  over  the  shoulders,  around  the 

Fig.  33. 


Cervico-brachial  Triangle. 


back  of  the  neck,  and  tie.  Draw  the  apex  back  beyond  the  elbow, 
fold  it  posteriorly,  and  pin  it  in  this  position.  If  the  triangle  is  n(jt 
long  enough,  a  cravat  may  be  tied  loosely  around  the  neck,  and  the 
ends  of  the  triangle  knotted  in  this. 

How  is  the  metatarso-malleolar  cravat  applied  ? 

Place  the  body  obliquely  across  the  back  of  the  foot,  cany  one 
end  around  the  foot,  the  other  around  the  ankle,  and  tie  in  front, 
over  the  back  of  the  foot. 

How  is  the  malleolo-phalangeal  triangle  applied? 

Place  the  base  in  the  hollow  of  the  foot.  Fold  the  apex  around 
the  toes  and  in  front  of  the  ankle  joint.     Carry  the  ends  around 


58  ESSENTIALS   OF  BANDAGING. 

tlie  foot,  cross  on  tlie  dorsum,  and  continue  around  tlie  malleoli ; 
then  back  to  the  dorsum,  securing  here,  or  continuing  to  the  side 
and  pinning. 

How  is  the  cervico-tibial  triangle  applied  ? 

Carry  a  cravat  from  the  top  of  the  shoulder  of  the  sound  side  to 
the  axilla  of  the  injured  side,  around  the  body  to  the  point  of 
starting,  and  tie.  Flex  the  leg  and  place  the  base  of  a  triangle  on 
the  tibia  just  above  the  ankle.  Carry  the  ends  up  and  tie  through 
the  cravat.  Bring  the  apex  around  the  knee,  and  pin  to  the  body 
of  the  handkerchief  Used  to  support  the  leg  when  it  is  fractured, 
and  the  patient  is  required  to  walk. 

How  is  the  figure-of-eight  of  the  knee  applied  ? 

Place  the  body  of  the  cravat  just  above  the  patella,  carry  the 
ends  back,  cross  in  the  popliteal  space,  bring  them  forward  just 
below  the  patella,  and  tie.  Used  to  approximate  the  fragments  of 
a  fractured  patella. 

How  is  the  tarso-patellar  cravat  applied  ? 

Place  one  cravat  as  a  figure-of-eight  of  the  knee,  loop  another 
cravat  around  the  foot,  just  anterior  to  the  ankle  ;  catch  the  body 
of  a  third  cravat  through  this  loop,  and  cany  its  ends  under  both 
the  lower  and  upper  segments  of  the  figure-of-eight,  and  secure  by 
pinning.     Used  to  approximate  the  fragments  of  a  broken  patella. 

How  is  the  tibial  cravat  applied  ? 

Place  the  body  obhquely  across  the  calf,  cany  the  ends  around 
the  leg,  one  below  the  patella,  the  other  above  the  malleoli.  Used 
to  retain  dressings. 

How  is  Barton's  cravat  applied? 

Place  the  body  of  the  cravat  around  the  posterior  surface  of  the 
point  of  the  heel,  with  the  end  corresponding  to  the  outer  side  of 
the  foot  one-thhd  longer  than  the  other.  Hold  the  inner  end  (short) 
parallel  with  the  foot,  while  the  long  end  is  carried  across  the  in- 
step, tui-ned  once  around  the  inner  end,  across  the  sole  of  the 
foot,  and  looped  around  itself  as  it  crosses  obliquely  over  the  instep. 
The  two  ends  are  knotted,  drawn  upon,  and  the  cravat  so  arranged 
that  traction  exerts  equal  pressure  ujum  dorsum  and  heel.  Used  to 
make  extension  for  fractured  femui'. 


PLASTER-OF-PARIS  DRESSINGS.  59 

Plaster-of-Paris  Dressings. 

Describe  the  plaster-of-Paris  bandag^e. 

To  be  of  service,  in  fixed  dressings,  plaster-of-Paris  must  be  dry 
and  fresh.  The  best  grade,  that  used  by  artists,  is  to  be  preferred 
in  surgical  practice.  It  may  be  applied  without  previous  prepara- 
tion by  making  it  into  a  thick  paste,  by  the  addition  of  water,  and 
smearing  it  generously  over  a  wet  muslin  bandage  after  the  latter 
has  been  applied  to  a  limb,  adding  one  or  two  more  layers  of  band- 
age and  of  plaster,  to  give  additional  strength.  It  is  usual,  however, 
to  prepare  the  plaster  bandages  previously ;  for  this  purpose  a 
sufiicient  quantity  of  crinoline  is  procured  and  cut  into  strips  five 
yards  long  and  three  inches  wide ;  into  the  meshes  of  this  loose 
fabric  the  plaster  is  then  thoroughly  nibbed ;  the  strips  are  rolled 
loosely  and  stored  in  a  tight  tin  can.  Where  a  great  many  jilaster 
bandages  are  used,  a  machine,  ingeniously  devised  for  the  proper 
distribution  of  the  plaster  through  the  fabric,  may  be  employed ; 
this  may  be  as  well  accomplished,  however,  by  the  hand.  A  small 
quantity  of  the  plaster  is  poured  into  a  pan  or  an  open  newspaper, 
and  by  means  of  the  fingers  can  be  evenly  distributed  through 
the  meshes  of  the  crinoline  as  the  latter  is  rolled. 

The  part  to  be  covered  is  protected  from  direct  contact  with  the 
plaster,  either  by  a  tightly-fitting  garment  in  which  there  are  no 
wrinkles,  or  by  a  thin  flannel  bandage ;  the  latter  should  not  be 
pinned.  The  rolls  of  plaster  bandage  are  then  placed  in  water  until 
ithey  are  thoroughly  soaked  through,  when  the  excess  of  moisture  is 
slowly  and  gently  squeezed  out  and  the  bandage  is  api)lied  with  just 
sufficient  pressure  to  make  it  lie  smoothly,  employing  as  few  reversed 
turns  as  possible .  As  the  bandage  is  unrolled  an  assistant  follows  it 
around  rubbing  in  the  plaster  and  making  it  perfectly  smooth  with 
his  wet  hands.  When  two  or  three  layers  of  bandage  have  been 
applied  a  couple  of  handfiils  of  dry  plaster  are  mixed  with  enough 
wateiuto  make  a  thick  paste  ;  this  is  smeared  over  the  outside  of  the 
bandage  and  smoothed  with  the  hands.  In  ten  or  fifteen  minutes 
the  bandage  should  be  fairly  well  set,  though  several  hours  must  be 
allowed  to  elapse  before  it  is  put  to  any  special  strain.  At  the  posi- 
tion of  joints,  or  at  any  part  of  the  bandage  where  breaking  from 


60  ESSENTIALS   OF  BANDAGING. 

motion  is  liable  to  occur,  thin  strips  of  wood,  zinc,  or  other  strong 
material  may  be  incori)oratcd  with  the  dressing.  If  the  plaster  band- 
ages are  in  the  first  place  wet  in  hot  salt  water,  hardening  will  take 
place  much  sooner.  In  cleaning  the  hands  after  the  bandage  is 
apiMied  the  dresser  should  not  use  soap  but  should  employ  simply 
warm  water  to  which  a  little  washing  soda  has  been  added. 

The  removal  of  the  bandage  is,  at  times,  a  matter  of  some  diffi- 
culty. This  may  be  accomplished  most  readily  by  splitting  it  up 
with  a  sharp  knife  before  it  is  thoroughly  hardened.  To  avoid  cut- 
ting the  surface  of  the  body  a  narrow  lead  strip  is  usually  placed 
outside  the  flannel  bandage,  in  the  long  axis  of  the  limb.  It 
should  be  of  sufficient  length  to  project  above  and  below  the 
plaster  after  it  is  applied.  The  cutting  can  be  done  safely  upon 
this  as  a  base. 

"Where  the  bandage  is  not  previously  cut,  a  little  vinegar  or  dilute 
hydrochloric  acid  and  a  sharp  knife  will  be  found  far  more  effica- 
cious than  the  plyers  and  saw  usually  employed.  The  bandage 
having  been  wet  in  the  Hue  of  incision  is  quickly  and  readily 
cut  through,  with  little  disturbance  of  the  parts.  The  hne  of  cutting 
should  be  kept  thoroughly  wet  with  the  vinegar. 

Under  what  circumstances  is  the  plaster  bandage  applied? 

1.  In  the  treatment  of  fractures  where  defoi-mity  is  absent  or  is 
readily  reduced,  and  where  great  swelhng  is  not  present. 

2.  In  sprains  and  in  chronic  inflammations  of  joints. 

3.  In  diseases,  deformities,  and  injuries  of  the  spinal  column. 

4.  As  a  jjermanent  splint  and  dressing  after  operation  upon  bones 
or  joints. 

5.  As  a  splint  after  the  performance  of  tenotomy  and  other  ortho- 
l)aedic  operations. 

How  is  the  plaster-of-Paris  bandage  trapped  ? 

The  surgeon  may  desire  to  inspect  a  wound  or  to  provide  for 
drainage  without  removing  a  plaster  bandage.  This  is  accomplished 
by  cutting  a  trap  or  window  in  the  dressing.  In  the  region  where 
the  opening  is  desired  a  thick  compress  of  gauze  is  placed.  This 
forms  a  projection,  when  the  bandage  is  completed,  which  not  only 
marks  the  position  of  the  trap,  but  which  enables  the  dresser  to  cut 
through  the  plaster  without  fear  of  injuring  the  j^atient. 


PLASTER-OF-PARIS  DRESSINGS.  61 

How  is  the  plaster-of-Paris  jacket  applied? 

The  plaster-of-Paris  jacket  is  applied,  in  cases  of  Pott's  disease, 
for  tlie  purpose  of  fixing  the  spine  and  to  relieve  the  diseased  ver- 
tebrae from  the  weight  of  the  upper  portion  of  the  body  ;  further, 
a  certain  amount  of  extension  may  be  obtained  if  the  dressing  is 
applied  carefully. 

The  body  of  the  patient  is  first  thoroughly  cleansed  with  boric 
acid  lotion  ;  a  tight-fitting  undershirt  is  then  put  on  ;  better  than  this 
is  a  stockinette  garment  or  one  of  silk  made  to  fit  perfectly  to  the 
figure.  In  any  case  the  shirt  should  reach  down  to  below  the  trochan- 
ters of  the  femur.  Bony  prominences  should  be  carefully  protected 
by  thick  pads  of  absorbent  wool  around  such  projections.  In  very 
thin  subjects  the  iliac  crests  will  require  padding.  Over  the  umbili- 
cus a  folded  towel  is  placed  ;  this  is  called  the  ' '  dinner  pad  ' '  and  is 
to  be  removed  after  the  bandage  hardens.  In  females  who  have 
passed  the  age  of  puberty  the  breasts  must  be  protected  by  thick 
layers  of  cotton  wool.  All  padding  is  placed  between  the  shirt  and 
tlie  skin.  When  everything  is  prepared  for  the  application  of  the 
plaster  the  patient  is  suspended  by  the  head  and  shoulders ;  the  ex- 
tension accomplished  by  this  means  must  be  slight,  otherwise  it 
becomes  unbearable  long  before  the  bandage  is  completed.  Suffi- 
cient traction  to  raise  the  patient  from  the  ground  so  that  his  toes 
are  touching  and  supporting  the  major  part  of  his  weight  is  all  that 
is  required.  Either  the  regular  extension  apparatus  may  be  em- 
ployed, or,  in  the  absence  of  this,  one  may  readily  be  improvised. 
A  hook,  a  cross-beam,  or  anything  over  which  a  rope  may  be  passed, 
a  rope,  a  stout  stick  two  feet  in  length,  and  bandages  are  sufficient 
for  all  practical  purposes.  A  broad  bandage  is  doubled  upon  itself, 
and  at  the  point  of  doubling  slit  up  the  middle,  in  its  long  axis,  for 
eight  inches  ;  the  bandage  is  opened  and  the  head  passed  through 
this  slit ;  on  making  traction  upward  one  portion  of  the  bandage 
catches  the  occiput  while  the  other  supports  the  chin.  This  occipito- 
mental sling  is  to  be  secured  to  the  middle  of  the  stick,  which  is  in 
turn  suspended  by  the  rope  immediately  above  the  patient' s  head. 
At  each  end  of  the  stick  two  bandages  are  looped  enabling  the  pa- 
tient to  support  himself  by  his  hands.  By  hoisting  on  the  rope  the 
patient  is  lifted  from  the  floor  to  the  desired  extent.  The  toes 
should  always  be  allowed  to  rest  upon  the  floor.     The  plaster-of- 


62  ESSENTIALS   OF  BANDAGING. 

Paris  bandages  are  then  placed  in  water  and  allowed  to  remain  until 
thoroughly  wet  through  ;  they  are  then  gently  squeezed  out,  to  rid 
them  of  excess  of  water,  and  are  applied  to  the  body,  from  just  above 
the  trochanters  of  the  femur  to  the  lower  borders  of  the  axillary 
folds.  As  the  bandage  is  carried  around  the  trunk,  an  assistant  rubs 
and  smooths  every  layer  with  his  wet  fingers.  The  turns  are  applied 
with  no  more  pressure  than  is  sufficient  to  make  them  lie  smoothly. 
In  children,  five  or  six  bandages  are  generally  required.  The  dressing 
is  comi^leted  by  taking  some  powdered  plaster-of-Paris,  mixing  it  with 
water  until  a  thick  paste  is  fonned,  and  thickly  smearing  the  latter 
over  the  entire  dressing  until  a  perfectly  smooth,  uniform  surface  is 
formed.  If  possible,  the  patient  should  remain  suspended  till  the 
bandage  becomes  well  set.  This  requii'es  ten  to  fifteen  minutes  ;  if 
this  is  too  fatiguing,  the  patient  should  be  laid  upon  his  back,  two 
assistants  supporting  him  upon  either  side  and  preventing  him  from 
bending  his  body.  After  the  bandage  is  thoroughly  hardened  the 
"  dinner  pad  "  is  removed. 


Adhesive  Plasters  and  Strapping. 

What  kinds  of  adhesive  plasters  are  commonly  used  ? 

The  adhesive  plasters  in  common  use  are  of  three  varieties— the 
resin  plasters,  isinglass  plasters,  and  the  rubber  adhesive  plasters. 

The  resin  plaster,  commonly  called  surgeon's  adhesive  plaster,  is 
the  one  most  commonly  employed.  It  is  slightly  stimulating  to  the 
surfiice,  adheres  firmly,  and  causes  but  little  irritation.  The  thin 
paper  covering  the  plaster  surface  is  taken  ofi",  and  the  plaster  is 
cut  in  strips  of  proper  width  and  length.  The  strips  are  heated  by 
passing  them  through  the  flame  of  an  alcohol  lamp,  or  by  holding 
the  unplastered  side  against  a  hot  vessel 

The  rubber  adhesive  plaster  requhes  no  heat ;  it  adheres  even  more 
closely  than  the  resin  plaster,  but  is  liable  to  cause  a  certain  amount 
of  irritation.  It  must  be  kept  in  contact  with  the  surface  for 
some  httle  time  before  it  firmly  adheres.  In  applying  it  care  should 
be  taken  to  shave  off  all  hairs,  as,  otherwise,  its  removal  is  quite 
painful. 

The  isinglass  plaster  must  be  moistened  before  it  will  adhere.     To 


ADHESIVE  PLASTERS  AND   STRAPPING.  63 

avoid  the  danger  of  infection  it  should  be  dipped  in  an  antiseptic 
solution  before  being  api^lied  to  a  fresh  surface. 
It  is  useful  in  dressing  small  wounds. 

For  what  purposes  are  straps  applied  ? 

(1)  To  retain  dressings. 

(2)  To  approximate  wounds. 

(3)  To  make  firm  and  uniform  pressure. 

Describe  the  method  of  strapping"  the  testicle. 

Indications. — Orchitis,  or  epididymitis,  after  the  swelhng  has 
reached  its  height. 

Application. — Shave  the  scrotum;  cut  twelve  to  eighteen  strips  of 
resin  plaster,  each  about  ten  inches  long  and  half  an  inch  wide.  Seize 
the  swollen  testis  and  pass  the  thumb  and  finger  around  the  scro- 
tum at  its  upper  portion,  making  circular  constriction,  and  enclosing 
the  injured  organ  in  a  tense  pouch  of  skin  ;  about  the  neck  of  this 
pouch  the  first  strap  is  passed  tightly  ;  this  holds  the  testis  in  place 
and  enables  the  operator  to  apply  pressure  by  means  of  subse- 
quent strips.  These  are  regularly  imbricated  one  above  the  other, 
the  first  beginning  at  the  circular  strip  and  passing  directly  across  the 
most  prominent  part  of  the  tumor.  Every  part  of  the  skin  must  be 
completely  covered,  and  the  strips  must  be  applied  evenly  and  regu- 
larly, so  that  uniform  pressure  is  made. 

This  dressing  gives  great  relief  to  the  intense  pain  which  charac- 
terizes inflammation  of  the  testes,  and  greatly  accelerates  resolution. 

Describe  strapping  of  the  breast. 

Straps  of  resin  adhesive  plaster  should  be  cut,  each  two  inches 
wide,  and  long  enough  to  pass  from  the  spine  of  one  scapula  forward, 
obliquely  upward  under  the  breast,  and  across  the  shoulder  to  the 
spine  of  the  opposite  scapula.  The  first  strap  is  applied  in  this  way; 
the  next  strap  is  applied  around  the  body,  overlapping  the  first  strap 
beneath  the  breast ;  the  third  strap  is  applied  obliquely^  again  over- 
lapping the  first ;  then  co-mes  the  circular  strap.  This  method  of 
application  is  continued  until  the  breast  is  entirely  covered. 

This  dressing  is  useful  in  inflammation  of  the  breast,  and  is  to  be 
preferred  to  the  roller  bandage  from  the  fact  that  it  does  not  pass 
completely  around  the  chest,  and  thus  breathing  is  not  interfered 
with. 


64  ESSENTIALS  OF  BANDAGING. 

Describe  strapping*  of  the  ribs. 

Strips  of  resin  plaster,  two  and  a  half  inches  wide,  and  long 
enough  to  reach  from  the  sternum  to  the  spine  are  employed  for  this 
dressing.  These  strips  are  applied  parallel  to  the  course  of  the  ribs. 
The  first  strap  is  secured  posteriorly  and  is  carried  around  the  side  of 
the  chest  as  close  to  the  axillary  folds  as  possible.  The  next  strap 
overlaps  this  downward  for  two-thirds  of  its  width  ;  the  straps  are 
thus  applied  until  the  injured  side  of  the  chest  is  covered  in. 

This  dressing  is  employed  for  fractures  of  the  ribs  and  for  hem- 
orrhage from  the  lung. 

Describe  the  strapping  of  an  ulcer. 

This  dressing  requires  straps,  each  one  inch  wide,  and  long  enough 
to  pass  two-thirds  around  the  limb  involved.  First,  the  ulcer  must 
be  thoroughly  cleansed,  and  the  parts  about  it  well  dried.  The 
straps  are  then  applied,  beginning  two  inches  below  the  lower  bor- 
der of  the  ulcerated  surface.  The  first  strap  is  applied  obliquely  to 
the  long  axis  of  the  limb,  with  its  middle  directly  below  the  middle 
of  the  ulcer.  The  next  strap  is  applied  at  right  angles  to  the 
first,  the  angle  of  crossing  lying  directly  below  the  ulcer  ;  each  suc- 
ceeding strap  is  applied  overlapping  upward  for  two-thirds  of  the 
width  of  the  straps,  until  the  ulcer  is  covered,  and  the  dressing  is 
continued  two  inches  above  its  upper  margin.  When  the  ulcerated 
surface  is  reached  the  tissues  of  each  side  should  be  drawn  together, 
the  straps  should  then  be  secured  to  one  side,  drawn  across  and  fastened 
to  the  opposite  side,  endeavoring  thus  to  bring  the  tissues  in  closer  ap- 
proximation. Over  this  dressing  a  sheet  of  lint,  or  a  thin,  even  pad 
of  absorbent  cotton  is  laid,  and  the  dressing  is  completed  by  a  tight 
spiral  reversed  or  figure-of-eight  bandage. 

This  dressing  is  peculiarly  valuable  in  the  treatment  of  chronic 
ulcers. 

Knots  and  Sutures. 

Describe  the  square  knot. 

Either  this  or  the  surgeon's  knot  is  the  one  commonly  employed 
to  secure  bleeding  vessels. 

The  square  Icnot  is  formed  hy  passing  one  end  of  a  cord  or  ligature 
over  and  around  the  other  end.     This  forms  a  sinsle  knot  which  is 


KNOTS  AND   SUTURES.  65 

drawn  tight.  The  two  ends  are  then  carried  toward  each  other  and 
the  same  end  is  again  carried  over  and  around  the  other.  On  draw- 
ing this  tight  the  square  knot  is  formed. 

The  surgeovb  s  knot  is  formed  by  carrying  one  end  twice  around  its 
fellow ;  after  tightening  of  this  double  turn,  the  same  end  is  carried 
over  its  fellow  again,  and  around,  as  in  case  of  the  square  knot. 

The  surgeon's  knot  is  harder  to  draw  tight  than  the  square  knot, 
but  there  is  less  liability  of  the  fii-st  turn  slipping  while  the  second 
securing  turn  is  being  formed. 

Dressers  are  usually  cautioned  not  to  make  what  is  called  the 
granny  knot.  The  difference  between  this  and  the  square  knot  lies 
in  the  fact  that  one  end  having  been  carried  across  and  around  its 
fellow,  the  knot  is  completed  by  carrying  this  same  end  under  and 

Fig.  34. 


Square  Knot. 

then  around  its  fellow,  or  what  amounts  to  the  same  thing,  carrj^ng 
the  end  which  was  first  crossed,  over  and  around  the  end  which  ori- 
ginally crossed  it.  In  reality  this  forms  a  secure  and  reliable  knot, 
and  the  objections  to  it  are  probably  purely  theoretical. 

The  square  knot  and  surgeon's  knot  are  commonly  employed  in 
securing  ligatures  and  in  tying  sutures. 

Of  what  materials  are  sutures  generally  made  ? 

Sutures  are  usually  made  of  silk,  silver  wire,  catgut,  silkworm  gut, 
or  horsehair.  Of  these,  the  catgut  alone  is  absorbable  ;  the  others 
must  be  removed  after  application. 

Describe  the  continuous  suture. 

(1)  This  is  also  called  the  glover's  suture.     The  needle  is  passed 
5 


ee 


ESSENTIALS  OF  SlTRGICAL  DRESSING. 


in  one  side  of  the  wound,  is  brought  out  the  other,  and  the  knot  is 
tied  ;  the  thread  is  then  carried  directly  across  the  wound,  the 
needle  is  again  plunged  in  the  same  side  as  in  the  fii'st  place,  is 


Fig.  35. 


The  Continuous,  or  GloTers'  Suture. 

carried  in  to  the  depth  of  the  wound,  is  brought  out  at  tbe  opposite 
side  and  the  thread  is  drawn  tight.  This  practice  is  repeated 
until   the  wound    is   completely   closed ;    the    short  end    of   the 

Fig.  36. 


rhe  Interrupted  Suture, 


thread  is  drawn  sufficiently  through  the  eye  of  the  needle  to 
allow  it  to  project  from  the  side  of  entrance  when  the  last  stitch  is 
formed  ;  to  this  single  thread  the  double  thread  is  tied.     This  forms 


KNOTS  AND  SUTimES. 


67 


a  continuous  over-hand  suture,    and  is   applicable  to    superficial 
wounds. 

Describe  the  interrupted  suture. 

The  interrupted  suture  is  formed  by  entering  the  needle  at  one 
side  of  the  wound,  carrying  it  down  to  the  deepest  part  and  bringing 
it  out  on  the  opposite  side  ;  the  suture  is  then  tied  with  either  the 
surgeon's  or  the  square  knot,  and  is  cut.  Each  stitch  is  made  sepa- 
rately, as  many  being  fjlaced  as  are  required  to  close  the  wound. 
In  this  suture  the  stitches  are  in  no  way  connected,  so  that  were 
one  to  break  the  others  would  still  continue  to  hold. 

What  other  sutures  are  commonly  employed  ? 

The  Plate  Suture. — The  end  of  the  suture  is  secured  in  a  broad 
leaden  button  or  plate  ;  the  needle  is  then  plunged  in  at  one  side  of 

Fig.  37. 


The  Plate  Suture. 

the  wound  tO  its  deepest  part,  is  brought  out  at  the  opposite  side 
and  is  secured  to  another  plate  or  button.  This  suture  is  valuable 
where  there  is  much  tension,  since  it  gives  a  broad  surface  for  the 
application  of  pressure. 

The  Pin  Suture.  — A  harelip  pin  is  entered  at  one  side  of  the 
wound,  carried  directly  across  its  deepest  j^art  and  brought  out 
through  the  skin  of  the  opposite  side.  Around  the  head  and  point 
of  this  pin  is  then  carried  a  thread  in  the  form  of  a  figure  of  8, 
approximating  the  lips  of  the  wound  and  making  sufficient  pressure 
to  check  hemorrhage  from  vessels  even  as  large  as  the  coronary 
artery. 

This  form  of  suture  is  of  value  when  it  is  desired  to  produce  close 
approximation,  and  at  the  same  time  check  bleeding. 


68 


ESSENTIALS  OF  SURGICAL  DRESSING. 


The  Quill  Suture. — Two  quills  are  cut,  each  the  length  of  the 
wound.  Each  needle  carries  a  double  thread  knotted  at  its  end. 
The  needle  is  entered  at  one  side  of  the  wound,  some  little  distance 
from  its  edge,  is  carried  across  the  depth  of  the  wound  and  brought 
out  at  the  other  side.     Through  the  loops  formed  by  the  knotting 

Fig.  38. 


iW/0^'"  i  '-^^^0^;^.,„ 


of  the  doubled  suture  is  passed  a  quill.  These  threads  are  then 
drawn  tight,  the  needles  are  cut  away,  and  the  two  ends  of  each 
thread  are  tied  around  a  quill,  placed  on  the  other  side  of  the 
wound,  parallel  to  its  long  axis.  This  is  applied  for  jDrecisely  the 
same  purpose  as  is  the  plate   or  button  suture  ;  great  tension  is 

Fig.  39. 


The  Quill  Suture. 

allowable,  since  it  is  distributed  over  a  large  surface,  and  thus  wounds 
are  drawn  in  close  apposition. 

The  Lembert  Sutt^re.  — This  suture  includes  only  the  serous, 
muscular  and  submucous  coats  of  the  bowel.     The  needle  is  entered 


KNOTS  AND  SUTURES. 


69 


at  one  side  of  the  wound  and  caused  to  penetrate  directly  through 
the  wall  of  the  bowel  until  the  sense  of  increased  resistance  caused 
by  the  tough  submucous  connective  tissue  is  felt ;  it  is  then  pushed 
along  at  right  angles  to  the  long  axis  of  the  Y/ound,  and  its  point  is 
made  to  emerge  on  the  same  side  of  the  wound  as  it  originally 
entered,  the  thread  including  about  a  fifth  of  an  inch  of  the  outer 
coats  of  the  gut.  The  thread  is  then  carried  directly  across  the 
wound,  the  needle  is  thrust  from  without  inward  down  to  the 
submucous  coat  of  the  bowel,  then  brought  out  again,  including 
the  outer  coats  as  before,  and  the  suture  is  tied.  This  thread  may 
be  interrupted  or  continuous.  In  either  case  the  stitches  are  placed 
from  an  eighth  to  a  tenth  of  an  inch  apart.     When  the  thread  is 

Fig.  40. 


The  Lembert  Suture. 


drawn  tight  the  two  serous  surfaces  are  approximated.  Fine  catgut 
or  China  silk  should  be  employed  for  this  suture.  The  needle 
should  be  small,  sharp,  and  with  a  perfectly  rounded  point,  having 
no  cutting  edges.     The  ordinary  milliner's  needle  answers  well. 

The  Czerny  Suture  differs  from  the  Lembert  in  the  fact  that 
the  edges  of  the  wound  are  brought  together  directly  by  carrying 
the  needle  through  the  serous  membrane,  out  at  the  wound  surface 
without  penetrating  the  mucous  membrane,  in  at  the  wound  surface 
of  the  opposite  side  superficial  to  the  mucous  membrane,  and  out 
through  the  serous  membrane.  By  these  sutures  the  lips  of  the 
wound  are  approximated  ;  further  security  against  leakage  is  insured 
by  a  row  of  Lambert's  sutures,  turning  in  the  wound  and  thus 


70 


ESSENTIALS  OF  SURGICAL  DRESSING. 


securing  apposition  of  serous  surfaces.     This  is  termed  the  Czerny- 
Lembert  suture. 


Fig.  41. 


The  Czerny  Suture. 

Sutures  of  Relaxation  are  those  which  are  brought  out  at 
some  distance  from  the  wound,  and  which  are  employed  for  the 
purpose  of  bringing  the  parts  together  where  otherwise  there  would 


Fig.  42. 


Sutures  of  Approximation  and  Coaptation. 


be  dangerous  tension  upon  the  stitches  which  close  the  skin  wound. 
For  this  purpose  quill  sutures  or  plate  sutures  are  commonly 
employed. 

Sutures  of  Approximation  are  those  which  are  carried  deep, 
and  are  designed  to  approximate  the  subcutaneous  parts  of  the 
wound. 

Sutures  of  Coaptation  are  those  which  puncture  only  the  skin. 
They  should  be  applied  so  accurately  that  they  practically  hermeti- 
cally seal  the  wound. 


ANTISEPTICS.  71 

"When  should  sutures  be  removed  ? 

This  depends  upon  the  amount  of  tension  exerted  upon  them. 
They  should  not  be  allowed  to  remain  longer  than  8  to  10  days,  as  a 
rule.  Sutures  about  the  face  should  be  taken  out  in  one  day  in  cases 
of  ordinary  wounds  ;  about  the  trunk  or  extremities  in  from  3  to  5 
daj^s.  After  laparotomy  or  where  newly-formed  tissues  will  probably 
be  subject  to  great  strain,  it  is  customary  to  leave  the  sutures  for 
from  8  to  12  days. 

How  are  sutures  removed  ? 

The  knot  is  seized  with  a  pair  of  fine  dressing  forceps,  slight  ten- 
sion is  exerted  upon  it,  and  by  means  of  a  pair  of  sharp-pointed  scis- 
sors the  thread  on  one  side  of  the  wound  is  divided ;  the  scissors 
are  then  placed  flat  upon  the  surfice  close  to  the  point  of  exit  of 
the  divided  thread,  and  the  latter  is  drawn  out  by  means  of  the  for- 
ceps. Where  silver  wire  has  been  emp)loyed,  after  cutting  the 
suture  the  wire  should  be  straightened  out  as  much  as  possible 
before  drawing  it  from  the  wound. 

Catgut  if  properly  prepared  will  be  absorbed  in  a  few  days.  The 
knots  only  will  have  to  be  taken  from  the  surface. 

"What  is  meant  by  secondary  suture  ? 

Under  certain  circumstances,  as  for  instance,  when  a  cavity  has 
been  opened,  and  the  surgeon  is  not  certain  that  suppuration 
may  not  follow,  the  sutures  are  inserted  as  usual  but  are  not  drawn 
tight,  the  wound  is  packed  with  iodoform  or  other  antiseptic  gauze 
and  the  dressing  is  applied.  After  a  few  days  the  gauze  packing  is 
removed  and  if  the  condition  of  the  wound  is  satisfactory  the  sutures 
are  knotted. 

ANTISEPTICS. 

"What  chemicals  are  req^uired  in  antiseptic  surgery? 

The  chemicals  usually  employed  are  bichloride  of  mercury,  car- 
bolic acid,  iodoform,  and  alcohol.  In  addition,  creolin,  sulphate  of 
zinc,  boric  acid,  and  peroxide  of  hydrogen  are  of  value. 

How  is  bichloride  of  mercury  used? 

It  is  used  in  watery  solutions  varying  in  strength  from  1-500  to 


72  ESSENTIALS  OF  SURGICAL  DRESSING. 

1-2000.  The  strength  of  1-500  is  used  solelj'^  as  a  means  of  cleansing 
external  j^arts.     In  the  strength  of  1-2000  it  is  used  for  irrigating. 

Where  large  cavities  are  to  be  washed  out  the  strength  should  not 
exceed  1-5000.  The  irrigating  solution  is  made  still  more  efficient 
by  the  addition  of  tartaric  acid.  This  prevents  the  neutralization 
of  the  mercury  by  albumiu.  If  it  is  desired  to  keep  solutions  of 
mercury  for  any  length  of  time  ordinarj^  salt  should  be  added,  as 
othei-wise  the  chloride  of  mercury  is  i3recipitated  in  the  form  of  an 
oxide,     (See  Appendix  for  Formulae.) 

Mercuric  solutions  are  also  useful  for  the  purpose  of  sterilizing 
dressings  and  renderiDg  them  antiseptic. 

An  alcohol  solution  of  mercury,  1-1000,  is  emploj^ed  for  the  pres- 
ervation of  silk  ligatures. 

What  symptoms  denote  poisoning  from  absorption  of  bi- 
chloride solution  ? 

There  is  at  first  a  feeling  of  giddiness  and  faiutness,  and  the  patient 
is  veiy  restless.  This  may  be  followed  by  vomiting,  foetid  breath, 
sahvation,  and  inflammation  and  ulceration  of  the  gums  and  mucous 
membrane  of  the  mouth.  In  severe  cases  there  is  often  diarrhoea, 
the  stools  being  blood-stained,  and  bleeding  from  the  mouth  and 
nose.     Albumin  and  mercury  are  found  in  the  urine. 

To  avoid  toxic  absorption  the  dressings  must  be  wrung  out  as  dry 
as  possible.  Yeiy  great  care  must  be  employed  in  children  and  in 
cachectic  patients  ;  and  in  irrigating  the  uterine  or  any  large  cavity 
even  the  most  dilute  solutions  should  not  be  employed. 

How  is  carbolic  acid  used? 

It  is  employed  in  the  strength  of  1-20  and  1-40.  The  1-20  solu- 
tion is  used  for  the  sterilization  of  instruments  and  for  the  cleansing 
of  surfaces.  The  1-40  solution  may  be  used  for  irrigation,  and  the 
washing  of  sponges  during  an  operation.  The  1-20  solution  benumbs 
and  cracks  the  hands  of  the  operator,  hence,  immediately  before 
operating,  this  liquid,  in  which  the  instniments  have  been  lying  for 
half  an  hour,  must  be  diluted  by  the  addition  of  an  equal  volume  of 
water,  making  the  lotion  of  a  strength  of  1-40.  On  account  of  its 
volatility,  the  1-20  solution  may  be  used  for  the  sterilization  of 
dressings  which  are  placed  in  contact  with  the  wound.     The  heat 


ANTISEPTICS.  73 

of  tlie  body  very  quickly  causes  evaporation  of  all  the  carbolic  acid, 
leaving  simply  a  sterile,  nou-ii-ritating  surface. 

What  symptoms  denote  poisoning  from  absorption  of  carbolic 
solution  ? 
The  urine  becomes  olive-green ;  the  intensity  of  the  coloration, 
however,  is  not  indicative  of  the  severity  of  the  poisoning.  The 
l^atient  complains  of  headache,  giddiness,  anorexia  and  vomiting. 
In  severe  cases  the  symptoms  are  followed  or  accompanied  by 
haemoglobinuria  and  bloody  diarrhoea,  death  following  from  collapse . 
Czerny  describes  a  chronic  form  of  poisoning  termed  carbolic  maras- 
mus, and  characterized  by  headache,  weakness,  anorexia  and  an 
irritative  cough. 

Describe  the  uses  of  iodoform. 

Iodoform  must  first  be  sterilized  by  a  thorough  washing  in  1-2000 
bichloride  solution.  It  is  then  kept  in  boxes  which  are  tightly 
closed.  It  is  employed  in  the  j)reparation  of  antiseptic  gauze,  and 
in  the  preparation  of  injection  oils  for  the  treatment  of  tubercular 
abscesses  (iodoform  one  part,  olive  oil  ten  parts) ;  it  makes  with 
collodion  a  dressing  for  superficial  wounds  ;  it  is  used  as  a  dusting 
powder  to  the  surface  of  wounds,  and  as  an  application  to  infected 
and  suppurating  wounds. 

What  symptoms  denote  poisoning  by  iodoform  ? 

This  drug  exerts  its  toxic  action  chiefly  on  the  heart  and  brain  ; 
usually  the  heart  first  shows  the  eff"ect  of  an  overdose,  the  pulse 
becoming  more  frequent  and  irregular.  The  patient  complains  of 
great  debility,  sleeplessness  and  headache,  and  suffers  from  extreme 
znental  depression. 

In  more  severe  cases,  in  addition  to  the  above  symptoms,  uncon- 
trollable restlessness  develops  into  delirium,  hallucinations,  or  any 
of  the  various  forms  of  acute  insanity.  These  symptoms  may  last 
for  weeks,  and  not  infrequently  end  in  death,  fi-om  cardiac  or  pul- 
monary depression. 

In  the  most  fatal  cases,  the  symptoms  of  acute  meningo-encepha- 
litis  are  followed  by  coma,  involuntary  passage  of  urine  and  faeces, 
and  other  signs  of  brain  pals}^ ;  here  a  fatal  termination  is  the 
rule. 


74  ESSENTIALS  OF  SURGICAL  DRESSING. 

Describe  the  uses  of  creDlin. 

Creolin  may  be  employed  precisely  as  is  carbolic  acid.  It  is 
devoid  of  the  toxic  properties  of  the  former  and  does  not  produce  irri- 
tation of  tlie  skin.  It  forms  with  water  a  mixture  rather  than  a  solu- 
tion ;  the  opacity  of  this  latter  is  an  objection  to  its  use  as  a  sterilizer 
of  instiTiments.  In  the  strength  of  3  to  5  per  cent,  it  is  an  efficient 
germicide ;  it  is  commonly  used  much  weaker,  but  bacteriological 
investigations  have  shown  that  this  is  not  safe. 

Describe  the  use  of  boric  acid. 

Though  not  possessing  great  power  as  an  antisei^tic,  solutions  of 
this  acid  are  of  great  utility  from  the  fact  of  its  being  non-toxic. 
Saturated  solutions  are  commonly  employed  (1  to  30  per  cent.). 
In  disinfecting  mucous  membranes  or  large  absorbing  cavities  boric 
acid  is  found  serviceable. 

Describe  the  uses  of  chloride  of  zinc. 

Chloride  of  zinc  is  commonly  used  in  the  strength  of  40  grs. 
to  the  ounce.  In  this  strength  it  is  a  powerful  antiseptic.  It  is 
employed  upon  raw  surfaces  known  to  be  infected  or  where  infection 
is  feared. 

Describe  the  use  of  peroxide  of  hydrogen. 

Peroxide  of  hydrogen  is  employed  in  the  sterilization  of  suppura- 
ting cavities.  It  comes  in  what  is  called  the  15-volume  solution, 
and  may  be  used  in  dilutions  of  from  10  per  cent,  upward,  or  in  full 
strength.  It  is  said  to  immediately  destroy  the  pus  microbes.  To 
granulating  surfaces  it  is  best  applied  in  the  form  of  a  spray. 


Sponges, 

How  are  sponges  prepared  for  operation? 

Sponges  may  be  prepared  by  being  thoroughly  washed  in  hot 
water,  dried,  and  well  beaten  until  they  are  freed  from  sand.  Cal- 
careous pailicles  may  be  farther  removed  by  steeping  them  in  a  1 0 
per  cent,  solution  of  hydrochloric  acid.  After  thorough  washing  in 
pure  water,  they  can  be  stored  in  1-20  carbolic  acid  solution.  A 
much  more  thorough  way  of  preparing  sponges  is  by  beating  out 
the  sand,  subsequently  washing  them  in  lukewarm  water,  then 


SILK.  75 

steeping  tliem  for  twelve  hours  in  a  mixture  of  one  part  of  solution 
of  chlorinate  of  soda  to  five  parts  of  water.  They  are  then  well 
rinsed  and  dried.  They  may  be  kept  eiiher  dry  in  tightly  closed 
jars,  or  in  1-20  carbolic  solution. 

It  is  not  advisable  to  use  sponges  more  than  once.  Where  this  is 
necessary,  however,  they  are  best  cleansed  by  being  steeped  in  a 
concentrated  solution  of  washing  soda,  well  washed  in  clear  water, 
and  immersed  for  an  hour  in  1-500  sublimate  solution. 


Catgut. 
How  is  catgut  prepared? 

The  bundles  of  catgut  which  come  in  commerce  are  freed  from 
their  bindings,  and  are  completely  immersed  in  oil  of  juniper  benies 
for  one  week,  when  they  are  removed  and  placed  in  absolute  alcohol, 
and  are  kept  indefinitely  in  this  material. 

The  chromic  catgut  is  made  by  tanning  this  material  with  chromic 
acid.  A  1-20  solution  of  carbolic  acid  is  prepared,  and  enough 
chromic  acid  is  added  to  make  a  solution  of  1-5000  of  the  latter 
drug.  The  catgut  is  immersed  in  this  solution  for  four  to  six  hours, 
or  until  the  gut,  when  lifted  out,  is  of  the  same  amber  color  as  the 
acid.  It  is  then  dried  and  packed  in  air-tight  flasks.  When  used 
it  should  be  soaked  for  half  an  hour  in  1-20  carbolic  or  1-1000  sub- 
limate solution. 

Silk. 

How  is  silk  sterilized  ? 

Silk  is  sterilized  by  boiling  for  half  an  hour.  It  is  subsequently 
stored  in  either  1-20  carbolic  solution,  or  in  absolute  alcohol,  to  which 
maybe  added  sufficient  mercury  to  make  a  1-1000  solution. 

Dressings. 

What  dressings  are  usually  employed  in  antiseptic  surgery? 

Bichloride  Gauze.— T\y[b  is  prepared  by  boiling  ordinary  cheese 
cloth  for  two  hours  in  water  made  moderately  alkaline  with  washing 
soda.  The  grease  is  thus  removed  and  the  fabric  is  rendered  absorb- 
ent.    The  soda  is  then  washed  out  and  the  cheese  cloth  is  again 


76  ESSENTLriLS  OF  SURGICAL  DRESSING. 

boiled  in  i)ure  water  for  two  liours,  after  wliicli  it  is  wniug  out, 
and  is  stored  in  sublimate  solution,  1-500.  When  the  dressing  is  to 
be  applied,  the  1-500  mercuric  solution  is  wrang  out,  the  fabric  is 
dipped  in  1-3000  solution,  is  again  wiTing  out  as  dry  as  possible,  and 
is  then  placed  on  the  wound. 

After  the  second  boiling  the  cheese  cloth  may  be  dried  in  the  sun 
and  stored  in  aii'-tight  jars  or  boxes.  When  used  it  can  be  dipped 
first  into  1-500  solution,  afterward  into  the  weaker  lotion  of  1-3000. 

Iodoform  Gauze. — This  is  most  readily  prepared  precisely  as  the 
bichloride  gauze,  except  that  after  the  cheese  cloth  has  been  thor- 
oughly wning  out  in  1-3000  con'osive  sublimate  solution  it  is 
sprinkled  liberally  with  iodoform,  and  the  latter  is  rubbed  thor- 
oughly into  its  mesbes.  The  layers  which  lie  in  immediate  contact 
with  the  wound  maj^  be  wniug  out  in  a  1-20  carbolic  solution.  The 
more  supei-ficial  layers  are  dipped  in  a  1-3000  bichloride  solution, 
and  are  then  dried  as  far  as  possible  by  squeezing  before  thej^  are 
applied.     Bichloride  cotton  forms  the  outer  laj'er  of  the  dressing. 

Protective. — Any  smooth,  readily  steiilizable  sui'face  wiU  answer  for 
this  part  of  the  dressing.  Lister's  iDrotective,  gutta-percha  tissue, 
oiled  silk,  or  even  waxed  paper,  may  be  used.  The  purpose  of  the 
protective  is  to  prevent  the  wound  fi'om  being  initated  either  by  the 
antiseptics  employed  in  tlie  gauze,  or  by  the  irregular  structure  of 
the  latter.  A  small  piece  is  taken,  just  large  enough  to  cover  the 
wound,  and  is  dipped  into  1-20  carbolic  solution.  The  latter  evapo- 
rates shortly,  and  leaves  a  sterile  surface  in  contact  with  the  wound. 
Many  surgeons  dispense  with  the  protective  entirely. 

Cotton. — Bichloride,  borated,  salicylated  or  plain  absorbent  cotton 
may  be  used.     The  bichloride  cotton  is  the  best. 

Bandages. — These  are  commonly  made  of  gauze,  and  conform  in 
size  to  the  regular  roller  bandage.  The  first  roUer  applied  should 
be  wrung  out  of  a  1-3000  bichloride  solution. 

Pins. — Either  the  ordinary  pins  or  safety-pins  are  employed. 
They  should  be  disinfected  by  means  of  carbolic  lotion  1-20,  and 
should  be  kept  in  absolute  alcohol 

Describe  Lister's  new  antiseptic  dressing. 

G-auze  prepared  as  above  is  impregnated  with  a  mixture  of  the 
cyanide  of  zinc  and  mercury  and  hsematoxylin.     This  gauze  is  either 


DRAINAGE.  77 

freshly  prepared  by  diifusing  the  powder  in  a  1-3000  bichloride  solu- 
tion, incorporating  it  with  the  gauze,  wringing  out  tlie  latter,  and 
applying  it  directly,  or  is  stored  damp  in  air-tight  jars,  to  be  used  as 
required.  The  first  layers  applied  directly  over  the  wound  are  wrung 
out  in  1-20  carbolic  lotion  ;  the  more  supei-ficial  part  of  the  gauze 
dressing  is  rendered  still  more  antiseptic  by  saturation  in  1-3000 
bichloride  solution.  Over  the  gauze  is  placed  a  thick  layer  of 
bichloride  cotton. 

Drainage. 

By  what  means  are  wounds' drained? 

Either  by  drainage-tubes  of  rubber,  bone  or  glass,  or  bj^  catgut  or 
horse-hair  drains.  The  most  efficient  way  to  drain  a  wound  is  to  leave 
it  open  and  pack  it  with  iodoform  gauze. 

When  it  is  possible  the  drainage-tube,  abundantly  provided  with 
fenestra  cut  in  its  sides,  should  pass  through  the  wound  from  side  to 
side,  so  that  it  may  be  readily  washed  out  in  case  it  becomes 
blocked,  or  may  be  cleaned,  if  necessarj^,  by  means  of  a  soft  catheter. 
Where  deep  cavities  are  to  be  drained,  the  tube  should  be  carried  to 
that  part  where  accumulation  of  fluid  is  most  liable  to  take  place. 
The  bone  drainage-tube  is  used  when  the  surgeon  does  not  intend  to 
remove  his  dressing  till  the  wound  is  healed.  In  comparatively  small 
wounds  catgut  or  horse-hair  may  be  employed.  The  former  is 
absorbable,  and  should  be  used  when  it  is  hitended  that  the  wound 
shall  heal  under  the  first  dressing ;  the  latter  has  to  be  removed. 
Drainage-tubes  are  removed  as  soon  as  they  cease  to  carry  off  dis- 
charge.    This  is  commonly  in  the  first  thirty-six  hours. 

When  may  drainage  be  omitted? 

In  incised  wounds,  when  there  is  no  reason  to  fear  that  infection 
has  occurred.  Wounds  as  large  as  those  resulting  from  excision  of 
the  breast,  if  aseptic,  require  no  drainage. 

Antiseptic  Operations. 

Describe  the  preparations  for  an  antiseptic  operation. 

The  surface  about  the  seat  of  operation  must  be  shaved  and  well 
washed  with  hot  soapsuds,  employing  a  clean  flesh  brush  vigorously. 
This  is  followed  by  a  thorough  washing  with  either  alcohol  or  ether, 


78  ESSENTIALS  OP  StTRGICAL  DRESSING. 

wliicli  removes  tlie  fat  from  tlie  surface  of  the  stin  and  from  tlie 
follicles,  and  enables  the  antiseptic  solution  to  act  upon  any  germs 
which  may  be  present.  The  next  washing  consists  in  a  carefid 
cleansing  with  1-500  solution  of  bichloride  of  mercury.  The  surface 
should  finally  be  completely  covered  with  a  bichloride  towel  soaked 
in  a  solution  of  1-1000.  The  operators,  assistants  and  nurses  then 
prepare  their  arms  and  hands  in  the  following  manner  :  The  sleeves 
are  rolled  up,  the  hands  and  arms  are  thoroughly  scrubbed  in  soap 
and  water,  by  means  of  a  nail  brush  the  nails  are  carefully  cleaned, 
and  the  hands  are  again  scrubbed  in  soap  suds.  Alcohol  is  then 
used  as  a  wash  for  two  minutes,  and  the  preparation  is  completed  by 
washing  the  hands  for  three  minutes  in  a  solution  of  bichloride  of 
mercury  1-1000.  After  this  final  washing,  the  hands  must  touch 
nothing  which  has  not  previously  been  sterilized  ;  and,  during  the 
course  of  the  operation,  the  surgeon  and  the  assistants  must  occa- 
sionally wash  their  hands  in  a  1-1000  solution.  When  everything 
is  prepared  for  the  operation,  the  table,  the  surface  of  the  patient's 
body,  and  the  clothing,  are  all  covered,  first,  by  rubber  cloth  or 
mackintosh,  then,  over  this,  are  spread  bichloride  towels,  soaked  in 
1-1000  solution,  so  that  the  surgeon  shall  not  inadvertently  touch 
non-sterilized  surfaces,  or  place  dressings  or  instruments  upon  them. 
In  the  meantime  the  dressings  are  cut  of  proper  size,  wrung  out  in 
the  proper  solutions,  and  wrapped  in  bichloride  towels. 

Describe  an  antiseptic  operation. 

The  instruments  having  previously  been  soaked  in  a  solution  of 
1-20  carbolic  acid,  at  the  moment  the  operator  is  about  to  begin  his 
work  sufficient  hot  water  is  poured  into  the  tray  containing  them  to 
make  a  solution  of  the  strength  of  1-40.  The  instruments  imme- 
diately required  are  then  selected  and  placed  on  one  of  the  bichloride 
towels  in  the  neighborhood  of  the  proposed  operation.  A  basin  con- 
taining sponges,  thoroughly  wrung  out  in  bichloride  1-2000,  is 
placed  within  reach  of  the  assistant.  A  nurse  stands  with  an  empty 
basin  ready  to  receive  the  blood-soaked  sponges,  which  are  imme- 
diately wnmg  out  again  in  1-2000  solution  and  placed  convenient 
to  the  hand  of  the  assistant.  Every  eff"ort  is  made  to  keep  the 
wound  exposed  as  little  as  possible.  During  any  intervals  of  opera- 
tion the  assistant  must  instantly  cover  the  entire  wound  by  sponges 


ANESTHETICS.  79 

or  by  a  wet  bicliloride  towel.  Wlien  the  upper  portion  of  tlie 
wound  is  the  seat  of  immediate  operation  the  lower  portion  must 
be  kept  covered,  and  vice  versa.  Bleeding  points  are  seized  in 
artery  forceps  or  hsemostats,  and  secured  by  catgut  ligatures.  On 
the  completion  of  the  operation,  bleeding  having  been  entirely 
checked,  the  wound  is  approximated.  The  edges  are  brought  together 
with  the  most  scrupulous  accuracy,  drainage  having  been  employed 
or  omitted,  according  to  the  will  of  the  surgeon. 

Describe  an  antiseptic  dressing^. 

The  wound  having  been  carefully  approximated,  iodoform  is  dusted 
upon  its  outer  surface,  and  a  piece  of  protective,  waxed  paj^er,  or 
other  perfectly  smooth  substance,  is  dipped  into  a  solution  of  1-20 
carbolic  acid,  cut  so  that  the  ends  of  the  drainage  tubes  may 
project  through  it,  and  placed  dhectly  over  the  line  of  suture.  This 
protective  must  be  just  large  enough  to  cover  the  wound,  and 
no  larger.  Over  the  protective  is  placed  the  deep  dressing. 
This  consists  of  eight  or  ten  layers  of  gauze  wrung  out  in  bichloride 
solution  1-3000  ;  or,  iodoform  gauze  may  be  employed,  when  irrita- 
tion of  the  skin  is  feared.  The  superficial  dressing  then  follows, 
being  composed  of  eight  or  ten  laj^ers  of  dry  gauze  prepared  with 
bichloride.  Over  and  around  this  is  laid  bichloride  or  absorbent 
cotton,  and  finally  a  bandage.  Each  application  must  be  overlapped 
throughout  its  whole  extent  by  the  next  superficial  dressing. 


ANAESTHETICS. 

How  is  ansesthesia  produced? 

General  anaesthesia  is  produced  by  the  administration  of  nitrous 
oxide,  ether  or  chloroform. 

Local  anesthesia  is  produced  by  freezing,  or  by  the  injection  or 
apphcation  of  cocaine. 

Which  is  the  safest  anaesthetic  ? 

Nitrous  oxide  for  operations  requiring,  at  the  most,  not  more  than 
two  minutes.  Ether  comes  next  in  order,  and  should  be  used,  even 
in  brief  operations,  when  muscular  relaxation  is  necessarj^o 


80  ESSENTL4LS  OF  StJRGlCAL  DRESSING. 

What  is  the  objection  to  the  use  of  chloroform? 

Sudden  death  frequently  occurs  from  cardiac  or  respiratory  arrest, 
and  without  premonitory  sj^mptoms.  This  is  hable  to  happen  when 
the  patient  inhales  while  in  a  sitting  position,  as  in  the  extraction  of 
teeth;  or  when  operations  are  begun  in  particularly  sensitive  re- 
gions, as  the  anus  or  vagina,  before  anaesthesia  is  complete. 

How  is  nitrous  oxide  administered  ? 

In  preparing  the  patient,  the  bladder  is  emptied  of  its  contents, 
the  clothing  about  the  neck  is  unbuttoned,  and  false  teeth  or  other 
loose  bodies  are  removed  fi'om  the  mouth. 

For  the  proper  administration  of  this  gas  a  receiver  or  cylinder 
attached  to  a  gas-bag,  and  a  mouth-piece  provided  with  a  double 
valve,  which  prevents  the  expired  air  from  passing  back  to  the  bag, 
should  be  provided.  The  patient  should  be  insti-ucted  to  take  deep, 
full  breaths.  In  from  thirty  to  sixty  seconds,  the  dusky,  congested 
face,  the  muscular  twitching,  and  the  stertorous  breathing  denote 
that  the  patient  is  fally  under  the  influence  of  the  gas. 

How  is  a  patient  prepared  for  the  administration  of  ether  or 
chloroform  ? 

A  careful  examination  of  the  urine  should  be  made,  and  the  con- 
dition of  the  lungs,  heart,  and  vascular  system  should  be  determined 
by  auscultation,  palpation,  and  an  examination  into  the  chnical  his- 
tory of  the  case.  For  at  least  six  hours  before  the  anaesthetic  is  ad- 
ministered, no  food  should  be  taken  into  the  stomach.  Anaemic  and 
excessively  neiTous  patients  should  receive  two  ounces  of  whiskey 
half  an  hour  before  being  anaesthetized.  In  dmnkards  a  quarter  of 
a  grain  of  morphia  renders  the  system  much  more  susceptible  to  the 
action  of  the  ether  or  chloroform.  Immediately  before  inhalation  is 
begun,  the  clothing  is  loosened  about  the  neck,  chest,  and  abdomen, 
and  artificial  teeth  or  other  foreign  bodies  are  removed  from  the 
mouth. 

The  physician  should  refuse  to  anaesthetize  women,  unless  there  is 
a  third  person  in  the  room.  Lights,  if  near,  should  be  held  above  the 
level  of  the  ether. 

How  is  ether  administered  ? 

A  towel  jnaj'  be  folded  in  a  cone,  or  simply  laid  over  the  mouth 
and  nose,  and  gathered  in  at  the  sides,  so  that  the  air  is  breathed 


ANAESTHETICS.  81 

in  through  its  meshes,  and  not  by  way  of  the  space  between  its 
borders  and  the  cheeks.  Of  the  many  inhalers,  that  of  x^lhs  is  the 
best.  It  consists  of  a  framework  cariying  many  folds  of  an  ordinary 
roller  bandage.  This  gives  a  broad  sm-face  for  the  rapid  evaporation 
of  the  ether.  If  possible  the  patient  should  lie  flat  upon  his  back. 
The  eyes  are  protected  by  a  folded  towel  placed  over  them.  During 
the  first  few  inhalations,  the  vapor  should  be  veiy  dilute,  excepting 
in  the  case  of  screaming  and  terrorized  children,  when  the  ether  should 
be  pushed  from  the  first.  As  soon  as  the  patient  becomes  slightly 
intoxicated,  the  vapor  should  be  as  concentrated  as  possible. 

Persistent  coughing,  swallowing,  and  attempts  at  vomiting,  indi- 
cate that  the  reflexes  are  not  abolished,  and  are  best  combated  by 
pushing  the  ether.  When  the  pulse  is  slow  and  full,  the  respirations 
deep  and  snoring,  the  reflex  irritability  totally  abolished,  and  the  pa- 
tient completely  relaxed,  the  anaesthesia  is  carried  to  the  extreme 
limit  of  safety. 

The  respiration,  the  pulse,  the  pupil,  and  the  color  of  the  skin, 
must  be  carefully  watched. 

In  what  ways  is  the  administration  of  ether  complicated  ? 

In  the  first  stage  the  patient,  though  still  partly  conscious,  may 
cease  to  breathe.  This  is  called  respiratory  forgetfulness,  and  is 
best  corrected  by  sudden  pressure  on  the  front  of  the  chest,  or  by  a 
dash  of  ether  on  the  epigastrium. 

In  the  second  stage  there  is  sometimes  a  tonic  spasm,  involving  the 
respiratory  muscles  and  accompanied  by  marked  venous  congestion. 
The  ether  should  be  withdrawn  till  this  complication  disappears. 
If  the  patient  has  eaten  solid  food  within  a  few  hours  and  vomits, 
he  should  be  rolled  over  on  his  side ;  it  is  not  sufficient  to  twist  the 
head  laterally. 

In  the  third  stage  respiration  may  be  seriously  embarrassed  by 
mucus  collecting  in  the  throat.  This  should  be  mopped  out  with 
small  sponges  firmly  secured  to  holders.  If  there  is  laryngeal  or 
pharyngeal  obstruction,  often  denoted  by  a  high-pitched,  crowing 
sound  on  inspiratoiy  effort,  the  lower  jaw  should  be  pushed  forward 
and  the  head  should  be  extended  by  upward  pressure  of  the  fingers 
placed  beneath  the  ramus  of  the  submaxillary  bone. 

Asphyxia  sometimes  threatens,  from  excess  of  ether,  from  drop- 
6 


82  ESSENTIALS  OF  STJHGICAL  DRESSING, 

ping  back  of  the  tongue,  or  from  closure  of  the  glottis.  The  surface 
becomes  blue,  the  pulse  frequent  and  irregular,  and  there  is  often 
laryngeal  or  crowing  stertor,  and  absence  of  respiratory  efforts. 

Immediately  the  head  must  be  extended  and  the  lower  jaw  must 
be  thrust  forward.  This  acts  upon  the  hyoid  bone,  elevates  the  epi- 
glottis and  opens  the  glottis.  Artificial  respiration  is  promptly  in- 
stituted, the  foot  of  the  table  being  raised.  Ether  or  ice  water  is 
dashed  on  the  bared  epigastrium,  and  the  electric  brush  is  applied 
intermittently,  the  sponge  electrode  being  placed  over  the  sternum 
or  any  indifferent  part,  while  the  wire  points  are  touched  to  the 
epigastrium  or  other  sensitive  parts  of  the  body  during  an  inspiratory 

Fig.  43. 


Method  of  Pubhing  the  Lower  Jaw  Forward,  where  there  is  Obstruction  to 

Breathing. 

effort.   Finally,  tracheotomy  may  be  performed,  when  the  lungs  can 
be  inflated  directly. 

A  twentieth  of  a  grain  of  strychnia  should  be  given  hypodermically 
as  soon  as  dangerous  symptoms  appear ;  this  may  be  repeated  once 
if  the  subsequent  course  of  the  case  makes  it  necessary.  Alcohol  and 
ammonia  seem  to  be  of  no  service,  while  ether  injected  hypodermi- 
cally is  obviously  not  to  be  commended. 

What  symptoms  denote  that  the  patient  should  have  more 
air? 

A  feeble,  infrequent  pulse.  Lividity  of  the  surface.  Laryngeal 
stertor.  Pallor  and  tonic  spasm.  A  pupil  suddenly  becoming  widely 
dilated  (a  sign  of  imminent  death).  Reversal  of  the  normal  respi- 
ratory movements  of  the  belly,  denoting  diaphragmatic  jDalsy. 


ANESTHETICS. 


83 


How  is  artificial  respiration  performel  when  dangerous 
symptoms  develop  during^  anaesthesia  ? 

The  table  is  tilted  up  till  it  makes  an  angle  of  45°  with  the  hori- 
zon, the  head  being  low. 

The  head  is  extended  so  that  it  rests  near  the  crown  upon  the 
surface  of  the  table,  the  eyes  looking  upward  and  somewhat  back- 
ward. At  the  same  time  the  under  jaw  is  pushed  well  foi-ward  by 
pressure  applied  behind  the  rami.  In  the  absence  of  assistants,  the 
drawing  forward  of  the  hyoid  bone  and  consequent  opening  of  the 
glottis  may  be  accomplished  by  letting  the  head  hang  over  the  end 

Fig,  44. 


Sylvester's  Method — ^Expiration. 

of  the  table.  The  surgeon,  standing  at  the  head  of  the  patient, 
then  seizes  him  by  the  arms  just  above  the  elbow  joints,  carries  the 
arms  partly  across  the  chest  toward  each  other,  and  throws  his 
weight  downward  so  that  the  lungs  are  emptied  of  the  anaesthetic 
vapor  which  may  remain  in  them.  The  arms  are  swept  in  a  semi- 
circle directly  out  from  the  sides  and  upward  till  they  extend  above 
the  head.  Firm  traction  is  made  for  two  seconds  to  further  fill  the 
chest  with  air.  The  arms  are  then  carried  down  to  the  chest  wall 
again,  where  by  pressure  the  lungs  are  made  to  expel  the  inspired 
air.  These  motions  are  repeated  from  twelve  to  sixteen  times  a 
minute,  and  practically  constitute  the  Sylvester  method  of  artificial 


84 


ESSENTIALS  OP  SURGICAL  DRESSING. 


respiration.  Howard's  metliod,  whicli  is  exceedingly  efficient,  is  aS 
follows  :  ' '  Make  the  head  hang  back  as  low  as  possible.  Place  tlie 
patient's  hands  above  his  head.     Kneel  with  the  patient's  hips  be- 


FlG.  45. 


Sylvester's  Method — Inspiration. 

tween  your  knees,  and  fix  your  elbows  firmlj''  against  your  hips. 
Now,  grasping  the  lower  j)art  of  the  patient' s  naked  chest,  squeeze 
]iis  two  sides  together,  pressing  gradually  forward  with  all  your 

Fig.  46. 


Howard's  Method — Expiration. 

weight  for  about  three  seconds,  until  your  mouth  is  nearly  over  the 
mouth  of  the  patient,  then,  with  a  push,  suddenly  ]erk  yourself 
back.     E-est  about  three  seconds,  then  begin  again,  repeating  these 


ANESTHETICS.  85 

bellows-blowiug  movements  with  perfect  regularity  for  at  least  one 
hour,  or  until  the  patient  breathes  naturally. 

Under  what  circumstances  is  chloroform  preferred  to  ether  ? 

Where  there  is  emphj^sema  of  the  lungs  or  bronchitis,  particularly 
in  the  aged  or  the  very  young.  Where  there  is  vascular  degenera- 
tion, or  disease  of  the  kidneys.  Where  operations  about  the  mouth, 
which  may  requhe  the  application  of  the  actual  cautery,  are  per- 
formed.    Where  it  is  necessary  to  give  an  anaesthetic  to  an  infant. 

How  is  chloroform  administered? 

The  patient  is  prepared  as  for  the  administration  of  ether.  Not 
more  than  a  drachm  of  chloroform  is  poured  upon  a  towel,  and  the 
latter  is  held  close  to  the  mouth,  but  not  touching  it,  otherwise 
painful  blistering  may  occur.  During  the  first  few  inhalations  suffi- 
cient air  is  allowed  to  avoid  giving  the  patient  a  sense  of  suffocation. 
Deep,  full  breaths  should  be  taken,  children  being  directed  to  blow 
out.  Absence  of  reflexes,  particularly  that  elicited  by  touching  the 
conjunctiva,  and  complete  muscular  relaxation,  denote  that  the 
patient  is  completely  anaesthetized.  Then,  and  not  till  then,  should 
the  operation  begin.  The  pupils  during  full  anaesthesia  are  com- 
monly contracted. 

Death  occurs  from  respiratory  arrest,  though  cardiac  syncope, 
with  a  fatal  issue,  is  common.  The  complications  and  their  treat- 
ment are  the  same  as  in  ether.  Prolonged  administration  seems  to 
have  been  followed  occasionally  by  fatty  degeneration  of  the  heart 
muscle. 

Under  what  circumstances  is  the  administration  of  chloro- 
form especially  dangerous  ? 

In  timid,  ansemic,  violently  hysterical  patients,  and  in  those 
exhibiting  the  signs  of  a  feeble  or  fatty  heart,  as  denoted  by  weak 
kregular  pulse  and  sluggish  peripheral  circulation.  In  angina 
pectoris  this  anaesthetic  should  not  be  given,  and  a  singularly  high 
mortality  has  attended  its  employment  in  operations  about  the  anus. 

How  is  cocaine  employed  for  the  production  of  local  anaes- 
thesia ? 

Mucous  membranes  are  angesthetized  by  the  application  of  solu- 
tions varying  in  strength  from  4  to  10  per  cent.     The  surface  to  be 


86  ESSENTLILS  OF  SURGICAL  DRESSING. 

anaesthetized  should  first  be  cleansed  bj^  a  boric  acid  wash  or  spray ; 
the  cocaine  is  then  apphed,  and  in  three  minutes  the  application  is 
repeated.  In  two  more  minutes  the  part  will  be  found  to  be  non- 
sensitive.  The  urethra  is  autesthetized  bj"  injecting  a  4  to  10  per 
cent,  solution  and  allowing  it  to  remain  for  three  minutes  ;  not  more 
than  two  grains  should  be  injected. 

When  minor  operations  are  to  be  performed,  such  as  the  amputa- 
tion of  a  finger,  circumcision,  or  the  removal  of  small  tumors,  a  2  to 
4  per  cent,  solution  is  injected  into  the  deeper  laj'ers  of  the  skin 
along  the  line  of  incision.  If  i^racticable,  a  mbber  band  is  placed 
around  the  field  of  operation,  so  that  the  circulation  is  enthely  inter- 
mpted.  This  prolongs  the  local  anaesthesia  and  prevents  rapid 
absorption  into  the  general  blood  current.  The  injections  must  be 
carried  as  deep  as  the  cutting.  When  the  patient  complains  of 
pain,  one  or  two  more  drops  may  be  injected  into  the  sensitive  part. 

To  avoid  many  punctures,  the  needle  is  entered  to  its  entire 
length,  and  one  or  two  drops  of  the  cocaine  solution  are  injected  ;  it 
is  then  withdrawn  a  quarter  of  an  inch  and  a  couple  of  drops  again 
injected :  this  is  repeated  till  the  point  of  the  needle  is  no  longer 
deep  enough  to  caiTv  the  injection  into  or  below  the  skin,  when  it  is 
entered  at  another  portion  of  the  proposed  incision  and  the  cocaine 
injected  as  before.  The  total  quantity  of  the  drug  injected  should 
not  exceed  Ij  grains. 

How  is  cold  employed  for  the  production  of  local  anaesthesia? 

The  simplest  way  to  produce  local  antesthesia  by  cold  is  by  means 
of  a  piece  of  ice  and  some  salt.  The  salt  is  liberally  sprinkled 
over  a  corner  of  the  ice,  and  the  latter  is  clapped  to  the  surface  of 
the  skin ;  in  less  than  two  minutes  the  skin  will  be  found  white, 
hard  and  frozen,  and  may  be  incised  without  giving  pain. 

Bj^  means  of  a  spray  of  rhigolene,  the  freezing  is  much  more 
quickly  accomplished,  is  less  painful,  and  is  more  superficial.  The 
spray  may  be  applied  by  means  of  an  ordinary  nasal  spray  apparatus. 
In  thuty  seconds  the  part  is  usually  non-sensitive  and  frozen. 


COUNTER-IRRITANTS-.  87 


Counter-irritants. 

Under  what  circumstances  are  counter-irritants  employed  ? 

(1)  As  general  vStimulants  in  conditions  of  acute  collapse. 

(2)  As  local  revulsants  in  cases  of  inflammation  or  congestion. 

What  materials  are  commonly  employed  as  rubefacients  ? 

Rubefacients  include  such  remedies  as  i}roduce  a  congestion  of  the 
skin  without  resulting  structural  change. 

This  may  be  accomplished  by  heat,  either  moist  or  dry,  by  heat 
alternating  with  cold,  by  turpentine,  by  mustard,  by  stimulating- 
lotions  such  as  chloroform  liniment,  by  capsicum. 

How  are  rubefacients  applied  for  their  constitutional  effect? 

They  are  applied  to  the  nape  of  the  neck,  to  the  wrists,  to  the  ab- 
domen, to  the  inner  surface  of  the  thighs  and  to  the  calves. 

How  are  hot  fomentations  applied  ? 

Two  thick  flannel  cloths  doubled  several  times,  and  a  vessel  of 
water  kept  constantly  at  a  temperature  of  about  120,  must  be  pro- 
vided. Both  cloths  are  thrown  into  the  hot  water.  One  is  removed, 
wiTing  out,  and  applied  to  the  surface  of  the  body  ;  it  is  at  once 
covered  with  waxed  paper  or  other  protective,  preventing  rapid  cool- 
ing ;  in  a  few  minutes  the  second  cloth  is  wrung  out  and  replaces 
the  first,  which  is  again  soaked  in  the  hot  water.  This  is  continued 
for  several  hours.  It  is  not  always  necessary  to  change  the  cloths  so 
frequently,  but  where  active  inflammation  is  to  be  combated,  good 
effects  will  be  obtained  only  by  constantly  maintaining  a  high  tem- 
perature. 

After  the  fomentations  have  ceased  the  part  should  be  protected 
by  cotton  or  flannel.  If  the  inflammation  thus  treated  has  involved 
any  portion  of  the  extremities,  a  pressure  bandage  should  follow  the 
application  of  heat  and  moisture. 

How  are  turpentine  stupes  applied? 

A  tliick  flannel  compress  is  wrang  out  in  hot  water,  its  folds  are 
then  opened  and  over  its  surface  turpentine  is  liberally  sprinkled  ; 
this  is  applied  directly  to  the  surface  of  the  bod}^  If  waxed 
paper  envelopes  this  dressing,  care  must  be  taken  to  see  that  the 


88  ESSENTLILS  OF  SURGICAL  DRESSING. 

turpentiue  does  not  act  too  violently,  as  severe  blisters  may  be  pro- 
duced iu  tlie  coui-se  of  an  hour.  A\"liere  no  protective  is  used  the 
turpentine  usually  evaporates  before  sufficient  time  bas  elapsed  to 
allow  of  vesication. 

How  is  mustard  employed  as  a  rubefacient  ? 

Mustard  may  be  used  as  a  dry  powder  sprinkled  sparingly  over 
tbe  surface  of  flannel  or  other  fabric  worn  in  immediate  contact  with 
the  skin.  It  may  be  added  to  a  local  or  general  bath,  in  the  propor- 
tion of  a  tablespoonful  to  the  gallon  of  water.  It  may  be  used  in  the 
form  of  a  plaster.  This  may  be  pm-chased  ready  for  immediate 
application,  or  may  be  made  from  ordinaiy  kitchen  mustard. 

Where  it  is  desired  to  leave  the  plaster  in  contact  with  the  sur- 
face for  upwards  of  five  minutes,  flour  or  other  inert  substance  must 
be  used  to  dilute  the  mustard.  Usually  two  parts  of  white  mustard 
and  one  part  of  flour  are  employed.  These  substances  are  thoroughly 
mixed,  and  to  them  is  added  enough  tepid  water  to  make  a  thick 
paste.  This  is  spread  in  the  middle  of  a  clean  cloth,  the  edges  of 
which  are  folded  in  so  that  the  mustard  is  prevented  from  extending 
beyond  the  desii^ed  hmits.  Over  the  surface  of  the  plaster  is  spread 
one  thickness  of  cheese-cloth  or  linen.  The  dressing  is  then  applied 
to  the  surface  of  the  body. 

Where  a  quick  effect  is  desired,  white  mustard  may  be  used  in 
full  strength.     Black  mustard  should  be  diluted  one-half. 

A  very  mild  counter-irritant  effect  may  be  obtained  by  mixing 
with  the  ordinary  flaxseed  poultice  a  few  teaspoonfals  of  the  mus- 
tard seed  flour. 

How  is  capsicum  used  as  a  rubefacient  ? 

This  may  be  employed  in  the  form  of  capsine  plaster,  found  in 
drug  stores,  or  may  be  incorporated  with  ginger,  cloves,  cinnamon 
and  honey,  making  the  well-known  spice  plaster. 

Describe  the  application  of  ammonia  as  a  rubefacient. 

This  may  be  applied  iu  the  form  of  a  liniment.  Where  very  rapid 
action  is  desired,  a  piece  of  lint  soaked  in  the  stronger  water  of  am- 
monia may  be  placed  upon  the  sui  "ace  of  the  body  and  covered  with 
waxed  paper  or  other  impervious  material.  It  must  be  borne  in 
mind  that  la  eight  or  ten  minutes  a  blister  can  be  raised  by  this  last 


COUNTER-IRRITANTS.  89 

metiiod,  hence  the  appHcation  should  not  be  continued  for  more 
than  two  or  three  minutes  at  most. 

For  what  purpose  are  vesicants  employed? 

Vesicants  are  apphcable  to  the  same  conditions  which  are  suitable 
for  the  employment  of  nibefacients.  They  are  employed  by  prefer- 
ence when  a  more  prolonged  and  jDowerful  action  is  desu'ed. 

What  materials  are  employed  in  producing^  vesication? 

Cantharides,  chloroform  and  ammonia. 

How  is  cantharides  employed  as  a  vesicant  ? 

Cantharides  may  be  used  in  the  form  of  the  cerate,  or  as  canthar  ■ 
idal  collodion. 

To  apply  it  in  the  form  of  cerate,  a  piece  of  ordinary  adhesive 
plaster  an  inch  wider  in  all  its  dimensions  than  the  size  of  the  blister 
desired  is  prepared.  Upon  the  central  portion  of  this  is  spread  a 
thin  layer  of  the  cerate.  The  plaster  is  slightly  warmed  and  api:>Hed 
to  the  surface,  when  it  maintains  the  blistering  cerate  in  close  appo- 
sition to  the  skin  as  long  as  necessaiy.  Before  applying  this  plaster 
the  skin  must  be  thoroughly  washed  with  soap  and  water.  In  six 
hours  the  plaster  is  removed  and  replaced  by  a  poultice.  The  poul- 
tice may  be  applied  at  the  same  time  as  the  vesicant,  directly  over  it. 

The  resulting  blister  should  be  cut  with  a  pair  of  scissors  at  its 
most  dependent  portion,  drained  of  its  serum,  and  di-essed  with  a 
sheet  of  lint  spread  with  boric  ointment. 

If  continued  counter-irritation  is  desired,  the  skin  raised  by  the 
blister  may  be  entirely  stripped  off,  and  the  raw  surface  may  be 
dressed  with  savine  ointment  or  other  irritating  applications.  It  is 
sometimes  desirable  to  apply  a  large  number  of  small  blisters,  and 
frequently  repeat  these  applications  rather  than  to  produce  an  ex- 
tensive vesication  ;  this  is  particularly  the  case  in  chronic  inflamma- 
tions. This  is  conveniently  accomplished  either  by  the  employment 
of  cantharidal  collodion,  or  by  smearing  pennies  with  a  thin  layer  of 
cerate,  and  fastening  them  in  place  with  adhesive  strips  or  a  roller 
bandage. 

The  cantharidal  collodion  is  conveniently  employed  when  the 
patient  is  refi'actory,  or  when  the  surgeon  is  not  certain  that  his 
directions  will  be  carried  out.  The  surface  to  be  blistered  is  pre- 
pared, if  possible,  by  poulticing ;  where  this  is  not  practicable  it 


90  ESSENTIALS  OP  SURGICAL  DRESSING. 

should  be  well  washed  with  soap  and  water.  Tlie  cantharidal  col- 
lodion is  then  painted,  for  two  or  three  minutes,  in  spots  the  size  of 
the  blister  desired.  The  subsequent  treatment  is  the  same  as  when 
the  cerate  is  used. 

What  precautions  must  be  observed  in  the  employment  of 
cantharides  ? 

Cantharidal  blisters  should  involve  only  very  small  surfaces  when 
applied  to  the  skin  of  the  old,  the  young,  the  feeble,  or  the  cachectic. 

Care  must  be  taken  to  see  that  sufficient  absorption  does  not  take 
place  to  produce  strangury.  This  complication  is  denoted  by  fre- 
quent, painful  micturition,  the  urine  commonly  containing  blood. 
It  is  avoided,  in  the  fii'st  place,  by  using  blisters  of  moderate 
size,  by  removing  them  in  from  four  to  six  hours,  especially  where 
there  is  reason  to  suspect  that  such  complication  may  occur  from 
the  existence  of  previous  irritation  of  the  bladder  or  kidneys,  by 
incorporating  with  the  cantharides  one-fourth  of  its  weight  of  cam- 
phor. 

How  is  strangury  treated  ? 

Where  this  complication  occurs  it  is  best  treated  by  opium  and 
belladonna  suppositories,  by  demulcent  drinks,  by  warm  sitz  baths, 
and,  if  severe,  by  leeches,  appHed  to  the  perineum  and  to  the  hypo- 
gastric  region. 

How  are  chloroform  and  ammonia  employed  as  vesicants  ? 

Chloroform  and  ammonia  are  rarely  used  except  in  cases  of  great 
urgency.  A  few  drops  of  chloroform  are  thrown  into  a  watch  crystal ; 
the  latter,  on  being  clapped  to  the  surface  of  the  body,  rapidly  pro- 
duces a  blister.  The  stronger  water  of  ammonia  may  be  used  in  the 
same  way,  or  may  be  employed  as  described  above  under  rabefa- 
cients,  the  application  being  continued  for  from  10  to  15  minutes. 

The  blisters  produced  by  these  agents  are  ijainful  and  severe,  and 
are  often  exceedingly  difficult  to  heal. 

Describe  the  formation  of  an  issue. 

An  issue  is  an  ulcer  intentionally  formed  by  the  use  of  the  knife, 
by  heat,  or  by  caustics.  Issues  are  rarely  emf)loyed  at  present, 
though  they  were  at  one  time  popular  as  a  means  of  causing  long- 
continued  count€r-imtation  and  depletion.     The  ulcer  is  commonly 


COUNTER-IRRITANTS.  91 

formed  by  caustic  potasli.  Several  thicknesses  of  adhesive  plaster, 
through  which  a  hole  has  been  cut,  are  applied  to  the  body.  On 
placing  the  potash  in  this  opening,  the  exposed  skin  is  destroyed, 
while  the  surrounding  surface  is  protected  by  the  plaster.  In  two 
hours  this  application  is  removed,  and  the  part  is  washed  with  a 
dilute  acid,  to  prevent  further  cauterant  action.  Whea  the  slough 
separates,  leaving  a  punched-out  ulcer,  the  latter  is  prevented  from 
heahng  by  the  presence  of  some  foreign  body,  such  as  a  small  pebble 
or  a  bean.  This  ulcer  may  be  dressed  daily  with  a  pledget  of  aseptic 
gauze,  kept  in  place  by.  adhesive  plasters. 

The  Moxa  is  a  small  pledget  of  combustible  material,  such  as 
l)unk,  which  burns  slowly.  This  is  placed  upon  the  surface  of  the 
body  and  igu'.tcd.  The  resulting  ulcer  is  treated  as  before.  On 
account  of  the  pain  attendant  upon  thus  forming  an  ulcer,  this 
method  is  no  longer  employed.  The  objection  to  the  employment 
of  the  knife  in  the  formation  of  an  issue  is  that  the  wound  closes 
rapidly. 

Describe  the  formation  of  a  seton. 

The  seton  is  used  for  the  same  purpose  as  the  issue.  It  is  simply 
a  subcutaneous  sinus  with  two  openings  upon  the  surface. 

It  is  formed  by  pinching  up  a  fold  of  skin,  thmsting  directly 
through  this  doubling  a  scalpel,  and  carrying  through  the  perfora- 
tion thus  made  an  eyed  probe  threaded  with  a  skein  of  silk. 

Each  time  the  dressing  is  changed,  the  silk  threads  should  be 
moved  somewhat. 

Describe  the  application  of  the  actual  cautery. 

The  actual  cautery  represents  the  most  powerful  means  of  revul- 
sion and  counter-irritation.  It  is  not  more  painfol  than  other  less 
feared  methods  of  counter-irritation. 

Heated  irons,  or  glass  rods,  or  the  Paqueliu  cautery  tips  are 
commonly  employed.  Before  making  the  application  a  vessel  of  ice 
water,  in  which  are  soaking  thick  flannel  cloths,  should  be  provided. 
The  cautery  should  be  heated  to  a  white  heat  and  should  be  applied 
either  to  one  spot,  or,  as  is  more  commonly  the  case,  should  be 
thawn  in  streaks  along  the  affected  area. 

Its  application  should  be  immediately  followed  by  placing  the 
cloths,  wrung  out  in  ice  water,  upon  the  bioi-n. 


92  ESSENTIALS  OF  SURGICAL  DRESSING. 

If  a  single  deep  burn  is  desired  the  portion  of  tlie  surface  to  be 
acted  on  may  be  frozen  by  ice  and  salt  before  the  application  of  the 
cautery. 

Where  Paquelin's  cauterj'  is  used,  care  must  be  taken  lest  ia 
over-heating  the  tijDS  the  instrument  is  destroyed. 


DEPLETION. 

.■m 

Describe  the  operation  of  blood-letting*. 

Blood  is  usually  drawn  from  the  median  cephalic,  the  median 
basilic,  or  the  external  jugular  yein.  The  guide  as  to  quantity  is  the 
pulse. 

The  operator  requires  roller  bandages,  a  small  antiseptic  dressing, 
and  a  lancet,  together  with  one  or  two  basins. 

If  the  blood  is  to  be  drawn  from  the  ,arm,  the  median  cephalic 
vein  should  be  preferred  ;  where  this  is  too  small,  the  median  basilic 
may  be  the  seat  of  operation.  It  must  be  remembered,  however, 
that  this  vein  is  in  close  proximity  to  the  brachial  artery  ;  the  latter 
should  be  protected  by  one  finger  of  the  operator  when  the  vein  is 
cut. 

The  patient's  arm  must  be  thoroughly  cleansed  by  the  antiseptic 
method  ;  it  is  then  encircled  at  about  the  middle  of  the  humerus  by 
a  few  circular  turns  of  the  roller  bandage,  applied  with  sufficient  firm- 
ness to  block  the  venous  chculation,  but  not  to  prevent  influx  of  blood 
from  the  brachial  artery.  The  patient  is  at  the  same  time  instracted 
to  grasp  as  firmly  as  he  can  a  roller  bandage  or  other  round  object, 
the  arm  being  held  in  a  dependent  position.  After  a  few  minutes 
the  veins  become  yery  conspicuous.  The  surgeon  thrusts  the  point 
of  his  lancet  down  beneath  the  vein  and  cuts  quickly  outwards,  mak- 
ing a  free  skin  opening.  A  careful  watch  is  kept  upon  the  pulse. 
AVhen  this  becomes  sufficiently  soft  and  slow  the  encircling  bandage 
is  removed,  the  wound  is  washed  with  bichloride  solution,  an  antisep- 
tic compress  is  applied,  and  the  limb  is  enveloped  in  a  roller  bandage 
from  the  fingers  to  the  axilla. 

In  case  of  apoplexy  or  inflammations  of  the  b/ain,  it  is  desirable 
to  bleed  from  the  external  jugular.    By  compressing  this  vessel  with 


CUPPING.  93 

the  finger  at  tlie  base  of  the  neck  it  may  be  made  sufficiently  promi- 
nent After  the  vein  is  divided  and  sufficient  blood  drawn,  the 
dressing  is  applied  and  retained  in  place  by  a  bandage  carried  around 
the  neck. 

The  precautions  to  be  observed  in  bloodletting  are  : — 

( 1 )  To  operate  under  all  antiseptic  precautions. 

(2)  To  wound  no  other  important  structure  than  the  vein. 

(3)  To  make  the  skin  incision  so  free  that  there  is  no  danger  of 
infiltration. 

At  times  it  is  exceedingly  difficult  to  find  the  veins.  Tliis  is 
especially  the  case  in  very  stout  persons.  Here  a  careful  dissection 
may  be  made  in  the  region  where  they  are  known  to  lie,  or  by  means 
of  a  candle  or  bright  light  their  position  in  the  subcutaneous  tissue 
can  be  determined  by  the  shadows  they  cast. 

Arteriotomy  is  sometimes  practised  in  cases  of  acute  inflamma- 
tions, especially  those  involving  the  eye. 

The  anterior  branch  of  the  temporal  artery  is  usually  selected,  as 
it  is  accessible  and  lies  on  a  firm  base,  against  which  pressure  can  be 
applied  for  the  control  of  bleeding  after  sufficient  blood  has  been 
di'awn. 

The  position  of  the  vessel  is  determined  by  its  pulsation. 

The  point  of  the  lancet  is  then  thrust  down  beneath  the  vessel ; 
the  latter  is  cut  transversely  entirely  through.  When  the  pulse  is 
sufficiently  modified,  a  firm  bandage  will  readily  control  bleeding. 


Cupping. 

Describe  cupping*. 

Cupping  may  be  either  dry  or  wet.  A  dry  cup  simply  draws  the 
blood  to  the  surface,  A  wet  cup  abstracts  blood  from  the  body. 
In  the  performance  of  either  of  these  methods  of  depletion,  regular 
cupping  glasses,  with  appliances  for  the  creation  of  a  vacuum,  or 
simply  ordinary  glasses  with  a  little  alcohol,  may  be  employed. 

If  the  ordinary  glasses  are  emploj^ed,  they  should  be  placed  mouths 
downward  upon  a  clean  towel,  and  a  candle  or  alcohol  lamp  should 
then  be  lighted.  Into  the  first  glass  is  poured  one  or  two  teaspoon - 
fuls  of  alcohol ;  this  is  rinsed  around  and  poured  into  a  second  glass. 


94  ESSENTIALS  OP  StmGICAL  DRESSING. 

The  excess  of  alcohol  in  the  first  glass  is  then  shaken  out,  the  glass 
is  pressed  against  the  towel  for  a  moment,  to  remove  any  drops 
which  may  have  run  down  to  its  edges,  and  is  then  placed  over  the 
candle  or  alcohol  lamp,  when  the  thin  film  of  fluid  remaining  is 
ignited.  The  glass  is  now  instantly  clapped  to  the  surface.  The 
contained  air  is  immediately  exhausted  by  the  burning  alcohol,  a 
powerful  vacuum  is  created,  and  the  flame  is  extinguished  even 
before  a  sense  of  warmth  is  appreciated  by  the  patient. 

Precautions. — All  excess  of  alcohol  must  be  removed,  so  that 
there  will  be  no  drops  running  over  the  surface  of  the  body  when  the 
glass  is  applied. 

The  mouth  of  the  glass  must  be  applied  closely  to  the  body,  as 
otherwise  air  will  enter  and  the  alcohol  still  continue  to  burn. 

These  cups  should  not  be  allowed  to  remain  in  one  place  more 
than  three  minutes,  as  otherwise  extensive  vesication  will  be  pro- 
duced. 

Describe  wet  cupping. 

Wet  cupping  is  performed  in  precisely  the  same  manner  as  dry 
cupping,  excepting  that  incisions  or  punctures  are  made  before  the 
application  of  the  cups ;  the  vacuum  thus  created  encourages  very 
free  bleeding. 

Leeching. 

Describe  leeching. 

Two  varieties  of  leeches  are  used,  the  American  and  the  Swedish. 
The  former  draws  about  a  teaspoonful  of  blood,  the  latter  three  to 
four  teaspoonfuls.     The  Swedish  leech  is  usually  employed. 

In  the  selection  of  leeches  care  should  be  taken  that  they  come 
from  clean,  pure  water.  Those  which  are  active  and  which  have 
smooth,  glazy  skins  are  to  be  preferred. 

The  leech  should  never  be  used  more  than  once. 

Surfaces  to  which  leeches  are  to  be  applied  should  be  thoroughly 
washed  and  shaved,  and  if  there  is  any  difficulty  about  inducing  the 
leeches  to  bite,  the  skin  should  be  smeared  with  a  little  milk  or 
bloodo 

The  leeches  are  placed  in  a  glass  or  a  wide-mouthed  jar,  and  the 
mouth  of  the  latter  is  clapped  to  the  surface  of  the  body. 


TRANSFUSION.  95 

When  tlie  leeches  have  drawn  sufficient  blood  they  can  be  induced 
to  let  go  by  dropping  salt  or  snuff  upon  them. 

The  bite  can  be  dressed  by  a  little  pledget  of  iodoform  gauze, 
together  with  a  pressure  bandage.  If  it  still  continues  to  bleed,  a 
small  pledget  of  styptic  cotton  may  be  employed,  or,  where  hemor- 
rhage is  very  obstinate,  a  hare-lip  pin  may  pass  through  the  centre  of 
the  bite,  and  the  latter  can  be  encircled  by  a  tight  ligature. 

Precautions. — The  leech  must  not  be  placed  over  the  arteries 
or  nerves,  or  upon  loose  cellular  tissue  such  as  the  eyelid  or  scrotum. 

In  the  application  of  leeches  about  mucous  cavities  care  must  be 
taken  to  see  that  they  do  not  escape  into  the  interior  of  the  body. 
This  can  be  prevented  by  plugging  the  continuation  of  the  cavity  oi 
by  securing  the  leech. 

Transfusion. 

Describe  transfusion. 

Transfusion  may  be  effected  by  either  the  immediate  or  direct 
method,  which  consists  in  carrying  blood  directly  from  the  vessels 
of  one  person  to  those  of  another  without  exposure  to  air,  or  by  the 
mediate  or  indirect  method.  In  the  latter  the  blood  is  drawn  into  a 
vessel  and  defibrinated,  then  injected  into  the  vessels  of  the  person 
requiring  it. 

In  the  direct  method  the  injection  is  most  readily  accomplished  by 
the  Aveling  apparatus.  This  is  practically  a  delicately  constnicted 
Davidson  syringe,  provided  at  each  extremity  of  the  supplj^  and  in- 
jection tube  with  a  canula  and  stop-cock.  The  syringe  is  first  filled 
with  normal  saline  solution  (.  7  per  cent. ) ;  the  median  or  basilic  vein 
of  the  patient  and  of  the  blood-giver  are  then  exposed.  The  two  arms 
are  placed  side  by  side,  and  into  the  vein  of  the  blood-giver  the  re- 
ceiving canula  is  secured,  with  its  extremity  pointing  toward  the 
hand.  The  canula  arming  the  extremity  of  the  injection  pipe  is 
then  thrust  into  the  vein  of  the  patient,  its  end  pointing  toward  the 
heart.  By  pressing  the  bulb  in  which  both  of  these  tubes  end,  the 
saline  solution  is  driven  into  the  circulation  of  the  patient.  On  re- 
leasing the  bulb  a  valve  shuts  off  the  suction  from  the  patient's 
blood,  while  another  one  allows  that  from  the  veins  of  the  blood- 
giver  to  again  fill  the  bulb.     By  alternately  emptying  tnd  filling  the 


96  ESSENTIALS  OF  SURGICAL  DRESSING. 

bulb  in  this  manner  a  sufficient  quantity  of  blood  Is  injected.  The 
capacity  of  the  bulb  being  known  the  total  amount  is  readily  calcu- 
lated. It  should  not,  however,  be  weighed  by  ounces,  but  by  the 
effect  upon  the  patient. 

The  indh-ect  method  consists  in  drawing  the  blood  from  the  donor 
into  an  aseptic  vessel,  whipping  it  with  broom  straws  to  separate 
the  fibrin,  straining  it  through  a  fine  linen  cloth,  and  injecting  it  into 
the  veins  of  the  patient,  preferably  by  means  of  a  clean  Davidson 
syi'inge  provided  with  a  canula. 

The  cardinal  objection  to  these  methods  lies  in  the  fact  that  human 
blood  is  no  more  efficacious  as  an  injection  into  the  veins  than  normal 
saline  solution;  that  it  is  often  difficult  to  find  a  healthy  person  will- 
ing to  supply  this  blood,  and  that  the  technique  requires  considerable 
skill  and  care. 

A  much  more  efficacious  means  of  supplying  volume  to  the  circu- 
lating fluid  as  a  means  of  tiding  over  an  emergency  is  afforded  by 
injections  of  sterile  normal  saline  solution  (.  7  per  cent. ).  A  vein  of 
the  patient  is  exposed  and  dissected  from  its  attachments  for  an 
inch,  and  two  hgatures  of  catgut  are  passed  beneath  it.  The  distal 
ligature  is  tied,  an  opening  is  made  into  the  vein  between  the  two 
ligatures,  a  canula  is  inserted  into  the  vein  lumen,  and  is  secured 
in  place  by  tying  the  proximal  ligatui'e.  By  means  of  a  dropper  this 
canula  is  then  filled  with  normal  sahne  solution,  after  which  it  is 
connected  with  a  pipe  attached  to  an  imgator  containing  one  or  two 
quarts  of  the  same  solution.  The  injection  is  continued  till  the 
pulse  responds. 


HYPODERMIC  MEDICATION. 

What  precautions  should  be  observed  in  administering  hypo- 
dermic medication  ? 

The  s3Tinge,  its  contents,  and  the  seat  of  operation  should  be 
sterilized. 

Large  vessels  and  important  neiTes  should  be  avoided. 

AYhen  the  solution  is  irritating  or  liable  to  give  much  pain  it 
should  be  injected  into  the  muscles. 


HYPODERMIC  MEDICATION.  97 

The  seat  of  puncture  sliould  be  dressed  with  iodoform  collodion, 
or  other  easily  applied  antiseptic  dressings. 

The  piston  rod  should  be  pressed  down  both  while  the  needle  is 
entering  the  subcutaneous  tissues  and  while  it  is  being  withdrawn. 

What  portions  of  the  body  are  selected  for  hypodermic  medi- 
cation ? 

Since  the  cellular  tissue  is  usually  selected  as  that  best  suited  to 
receive  the  medication,  and  since  the  solutions  used  generally  give 
more  or  less  pain,  the  least  sensitive  portions  of  the  body  provided 
with  a  thick  layer  of  superficial  fascia  are  usually  selected.  It  is 
commonly  stated  that  absorption  is  more  rapid  from  the  inner  sur- 
faces of  the  arm  and  forearm.  This  is  the  popular  region  for  injec- 
tions ;  less  pain  will  be  experienced,  however,  when  the  needle  is 
driven  into  the  outer  surfaces  of  the  thighs  or  buttocks. 

As  a  general  rule,  it  may  be  stated  that  when  morphia  is  injected 
for  the  purpose  of  controlling  pain  it  should  be  inserted  as  near  the 
seat  of  pain  as  possible. 

How  may  pus  formation  be  avoided  in  hypodermic  medica- 
tion? 

By  observing  the  principles  of  antiseptic  surgery.  In  an  ordi- 
narily healthy  body  the  most  imtating  medications  may  be  injected 
without  fear  of  abscesses,  provided  proper  precautions  in  regard  to 
the  sterility  of  the  solution,  and  the  instrument  by  which  it  is  in- 
jected are  observed.  Standard  solutions  should  not  be  kept,  but  the 
drug  indicated  should  be  dissolved  in  boUed  water  immediately  be- 
fore it  is  employed. 

How  can  the  hypodermic  syringe  be  kept  aseptic  ? 

After  the  needle  has  been  used  it  should  be  boiled  and  subsequently 
kept  in  absolute  alcohol.  The  syi'inge  should  be  washed  out  in 
carbolic  or  in  saturated  boric  acid  solution,  and  should  be  pro\aded 
with  a  cap  which  renders  it  air  tight. 

How  do  you  administer  hypodermic  injections? 

A  sterile  solution  is  drawn  into  the  barrel  of  a  sterile  syringe ;  the 
needle  is  secured  in  place,  and  the  piston  is  pressed  up  till  all  the  air 

escapes. 
The  method  of  injection  which  gives  least  pain  consists  in  quickly' 
7 


98  ESSENTIALS  OF  SURGICAL  DRESSING. 

plunging  the  needle  to  the  depth  required  directly  into  the  tissues, 
beginning  the  injection  the  moment  its  point  has  penetrated  through 
the  skin,  and  pressing  the  last  drops  from  the  barrel  just  before  the 
point  of  the  needle  is  again  withdrawn.  AVhere  muscular  injections 
are  given,  and  these  in  all  instances  are  less  liable  to  give  rise  to 
local  troubles,  the  needle  may  be  thrust  in  to  its  full  length.  Where 
a  more  supei-ficial  injection  is  desired,  the  depth  of  insertion  may  be 
controlled  by  the  thumb  or  finger  placed  upon  the  shaft  of  the 
needle  and  acting  as  a  guard  against  too  great  i^enetration.  AYhen 
the  point  of  the  needle  is  kept  well  sharpened  the  sudden  thrust  gives 
almost  no  pain. 
As  ordinaiily  practised,  the  skin  is  pinched  up  in  a  fold  between 

Fig.  47. 


Hypodermic  Injection. 

the  thumb  and  forefinger  of  the  left  hand  ;  into  one  end  of  this  fold 
the  needle  is  inserted  obliquely,  by  either  slowlj^  forcing  it  through 
the  tissues  or  by  a  sudden  thrust.  The  injection  is  then  driven  out 
of  the  cylinder,  the  needle  is  withdrawn,  and  the  puncture  is  closed 
by  the  application  of  iodoform  collodion. 

What  accidents  may  occur  in  the  administration  of  hypoder- 
mic medication? 

(1)  Should  the  needle  point  penetrate  a  large  vein,  the  whole  of 
the  injection  fluid  may  pass  immediately  into  the  general  circulation 
and  produce  serious,  or  even  fatal,  consequences. 

(2)  Should  the  injection  lie  in  the  immediate  neighborhood  of  a 
sensitive  nerve,  very  great,  and  even  lasting,  jjaiu  may  be  produced. 


FRACTURE  DRESSINGS.  99 

(3)  Sliould  tlie  injection  contain  septic  germs,  abscesses  will 
probably  form. 

Describe  the  method  of  administering  large  hypodermics. 

Where  much  blood  has  been  lost,  so  that  the  patient  is  in  danger 
of  death  from  emptiness  of  the  vascular  system,  large  hypodermic 
injections  may  be  employed  in  place  of  forcing  the  liquid  directly 
into  the  veins  or  arteries.  For  this  purpose,  a  j&ne  aspirating  needle 
and  an  ordinary  irrigating  apparatus  suffice. 

An  area  of  the  body  containing  a  thick  layer  of  superficial  fascia 
is  selected.  The  aspirator  is  thrust  into  this,  the  trocar  is  with- 
drawn, a  rubber  tube  leading  from  the  irrigator  is  attached  to  the 
canula,  and  the  solution  is  allowed  to  flow  in  by  gravity,  its  absorp- 
tion being  promoted  by  gentle  massage.  In  this  way  one  or  two 
quarts  of  saline  solution  may  readily  be  injected. 


FRACTURE-DRESSINGS. 

What  are  the  general  principles  governing  the  dressing  of 
fractures  ? 

The  fracture  should  be  reduced  before  the  dressings  are  applied, 
the  purpose  of  splints  being  merely  to  retain  the  parts  in  the  position 
in  which  the  surgeon  has  placed  them. 

All  dressings  should  be  inspected  daily  during  the  week  following 
a  fracture.  In  case  of  severe  and  lasting  pain,  swelling  and  oedema 
of  parts  peripheral  to  the  injury,  or  loosening  and  displacement  of 
the  splints  and  bandages,  the  dressing  must  be  reapplied. 

After  inflammatory  symptoms  have  subsided,  the  seat  of  injury 
should  be  disturbed  as  little  as  possible.  The  dressings  should  be 
inspected  frequently,  but  should  not  be  taken  down  oftener  than 
once  a  week,  unless  they  become  loose  or  uncomfortable. 

Splints  should  be  carefully  padded  to  fit  the  surfaces  to  which  they 
are  to  be  applied.  Bony  prominences  should  be  protected  from 
undue  pressure  by  cotton  or  oakum,  twisted  into  a  ring  and  placed 
around  such  prominences. 

The  splints  should  retain  the  fragments  in  their  proper  position 
and  should  fix  both  the  joint  above  and  the  joint  below  the  injury. 


100  ESSENTIALS  OF  SURGICAL  DRESSING. 

When  tlie  diagnosis  of  fracture  cannot  positively  be  determined 
the  injury  should  be  treated  as  though  it  were  a  fracture,  till  subsi- 
dence of  swelhng  enables  the  surgeon  to  determine  the  nature  of  the 
injury. 

When  the  fracture  is  readily  reduced,  and  when  there  is  not 
great  swelling,  the  plaster-of-Paris  dressing  may  be  employed.  This 
should  be  carefully  watched  to  see  that  with  the  onset  of  swelling  it 
exerts  no  injurious  pressure. 

How  are  fractures  of  the  lower  jaw  dressed? 

After  careful  reduction  of  deformity  the  fracture  is  dressed  in  a 
moulded  pasteboard  splint,  or  trough,  which  extends  back  laterally 
as  far  as  the  ramus,  and  beneath  to  the  hyoid  bone.  This  is  well 
padded  and  kept  in  place  by  either  a  Barton  or  a  Gribson  bandage. 

In  this  dressing  the  lower  jaw  is  practically  splinted  upon  the 
upper.  Where  the  dental  conformation  is  very  irregular  it  may  be 
necessary  to  insert  between  the  teeth  of  the  upper  and  those  of  the 
lower  jaw  a  moulded  arch  before  perfect  apposition  can  be  main- 
tained. 

In  case  this  dressing  is  not  successful  the  fragments  should  be 
drilled  and  wired  together. 

How  are  fractures  of  the  clavicle  dressed  ? 

Fractures  of  the  clavicle  may  be  dressed  by  means  of  the  Yelpeau 
or  Desault  bandage,  or  by  Sayre's  adhesive  plaster  dressing.  The 
choice  of  dressings  will  depend  upon  the  seat  and  nature  of  the  frac- 
ture. In  general  it  may  be  stated  that  the  arm  and  shoulder  should 
be  bandaged  in  that  position  which  secures  most  accurate  apposition 
of  the  ends  of  the  broken  bone. 

The  Velpeau  and  Desault  dressings  have  already  been  described. 

The  Sayre  dressing  consists  of  strips  of  adhesive  plaster,  three 
and  a  half  inches  wide.  The  first  is  long  enough  to  surround  the 
body,  including  the  arm  ;  this  strip  encircles  the  arm  over  the  inser- 
tion of  the  deltoid,  in  the  form  of  a  loosely  fitting  loop  which  must 
be  made  secure  by  sewing.  The  arm  is  drawn  somewhat  downward 
and  backward  in  order  to  make  the  clavicular  origin  of  the  pectoralis 
major  muscle  tense.  It  is  secured  in  this  j)osition  by  carrying  the 
strip  entirely  around  the  body  and  fastening  it  to  itself  in  the 
back.     The  second  strijj,  beginning  at  the  sound  shoulder,  is  earned 


FRACTURE  DRESSINGS. 


101 


obliquely  across  the  back  to  tlie  elbow  of  tbe  iujured  side.  The  olec- 
ranon is  received  in  a  slit  made  in  the  plaster,  to  avoid  injurious 
pressure  upon  this  bony  point.  The  strij)  is  then  carried  upward 
across  the  front  of  the  chest  to  its  point  of  origin. 

Fractui'es  of  the  clavicle  may  also  be  secured  by  means  of  a  plaster- 
of-Paris  bandage.  In  this  case  the  patient  should  be  placed  in  a 
recumbent  position  upon  a  hard  flat  surface.  This  secures  almost 
perfect  replacement  of  the  broken  bones.  The  dressing  is  now 
applied,  the  arm  being  held  across  the  chest.  TThen  this  bandage 
hardens  the  patient  is  allowed  to  rise  from  the  bed. 


Fig.  48. 


Fig.  49. 


Fig.  50. 


Sayre's  Dressing. 


How  are  fractures  of  the  scapula  dressed  ? 

Fractures  of  the  hotly  of  the  hone  are  secured  in  place  by  com- 
presses placed  along  the  anterior  and  posterior  margins.  These  are 
held  by  broad  strips  of  adhesive  plaster  encircling  one-half  the  chest. 
The  arm  should  be  bandaged  to  the  side  and  the  forearm  slung  at 
the  wrist. 

Fractures  of  the  acromion  are  best  treated  by  the  thu'd  roller  of 
Desault.  The  arm  should  be  secured  to  the  side  and  slung  at  the 
wrist. 

Fractures  of  the  Corancoid  Process  are  treated  by  bandaging  the 
ami  in  the  Yelpeau  position. 

Fractures  of  the  surgical  necl-  are  treated  by  the  second  and  third 


102 


ESSENTIALS  OF  SURGICAL  DRESSING. 


rollers  of  Desault,  the  arm  being  held  vertically  by  the  side  of  the 
chest,  and  the  forearm  being  slung  at  the  wrist. 

How  are  fractures  of  the  humerus  dressed  ? 

Fractures  of  the  upper  extremity  of  the  humerus  are  treated  by 
the  shoulder  cap,  the  side  of  the  body  acting  as  the  internal  splint. 

The  shoulder  cap  may  be  moulded  out  of  card  board.  It  should 
cover  the  upper  and  posterior  aspects  of  the  shoulder,  and  should 
extend  as  low  as  the  external  condyle  of  the  humerus,  encircling  two  • 
thirds  of  the  arm.  A  pattern  may  be  cut  from  ordinary  paper ;  a 
piece  of  thick  cardboard  is  then  shaped  properly  and  is  dipped  into 


Fig.  51. 


Dressing  for  Fracture  of  the  L^pper  Third  of  the  Humerus. 

hot  water.  A  spiral  reversed  bandage  is  applied  to  the  injured 
Hmb  up  to  the  axilla,  the  pasteboard  is  removed  from  the  hot  water, 
is  padded  with  a  thin  layer  of  cotton,  is  moulded  to  the  shoulder 
and  humerus,  and  is  secured  in  place  by  a  few  turns  of  the  roller. 
A  folded  towel  is  placed  in  the  axilla,  the  arm  is  brought  to  the  side 
with  the  elbow  a  little  to  the  front,  and  is  secured  in  this  position  by 
circular  turns  passing  around  the  side  of  the  chest  and  the  outer 
aspect  of  the  shoulder  cajD.  The  dressing  is  completed  by  slinging 
the  forearm  at  the  wrist. 

Fractures  of  the  shaft  of  the  humerus  iRSiy  be  treated  by  an  internal 
rectangular  splint,  extending  from  the  axilla  to  the  tips  of  the  fingers. 
Care  must  be  taken  to  see  that  the  short  arm  does  not  extend  far 


FRACTURE-DRESSINGS. 


103 


enough  into  the  axilla  to  cause  injurious  pressure  at  this  point.  If 
the  splint  is  not  fenestrated  at  its  angle  to  receive  the  internal  con- 
dyle, it  must  be  most  carefully  padded  at  this  point.  In  addition 
to  this  splint  either  the  shoulder  cap,  or  three  short  splints  are 
required.  A  primary  roller  (spiral  reverse)  is  applied,  extending  up 
to  the  axilla.  The  arm  is  then  secured  upon  the  internal  rectangular 
splint,  and  either  the  shoulder  cap  is  applied,  or,  in  place  of  this, 
three  short  splints,  one  in  front,  one  behind  and  one  to  the  outer 
aspect  of  the  humerus,  are  employed.  The  arm  is  slung  at  the 
wrist. 

Fig.  52. 


Internal  Angular  Splints. 


This  fracture  is  also  dressed  by  means  of  a  short,  straight  internal 
splint,  extending  from  the  axilla  to  the  internal  condyle,  and  the 
long  shoulder  cap,  used  in  fractures  of  the  upper  extremity  of  the 
bone.  The  primary  roller  is  applied  as  before,  the  inner  splint  is 
secured  in  place,  the  shoulder  cap  is  applied  and  the  arm  is  band- 
aged to  the  side  by  circular  turns  about  the  body,  the  forearm  being 
supported  at  the  wrist. 

Fractures  of  the  lower  extremity  of  tlie  humerus  should  be  treated 
by  means  of  the  anterior  angular  splint  together  with  the  posterior 
moulded  trough.  In  fractures  of  the  external  coudjde,  the  angle 
of  this  splint  should  be  obtuse. 


104 


ESSENTIALS  OF  SURGICAL  DRESSING. 


In  supracondyluid  fractures  tlie  angle  may  be  acute.  The  spiral 
reversed  bandage  is  applied,  extending  up  to  the  axilla,  and  the 
carefully  padded  splint  is  then  placed  on  the  anterior  surface  of  the 
arm  and  forearm,  the  hand  being  held  in  supination.  Backward 
displacement  of  the  lower  fragment  is  prevented  by  a  trough  applied 
to  the  posterior  aspect  of  the  elbow.  These  dressings  are  held  in 
place  by  a  carefully  applied  roller  bandage.  The  arm  is  slung  at  the 
wrist.  Splints  of  various  angles,  or  a  single  splint,  the  angle  of 
which  can  be  changed,  must  be  provided  in  the  treatment  of  these 

Fig.  53. 


Anterior  Angular  Splints. 

fractures,  since  otherwise  anchylosis  or  impairment  of  motion  is  veiy 
liable  to  result.  Passive  motion  should  be  begun  as  soon  as  acute 
inflammatory  symptoms  have  subsided.  After  two  weeks  this  motion 
may  be  considerable. 

How  are  fractures  of  both  bones  of  the  forearm  dressed  ? 

With  the  exception  of  fractures  of  the  olecranon  the  primary  roller 
is  never  applied  to  fractures  of  the  forearm,  since  otherwise  the  inter- 
osseous space  would  be  encroached  upon,  and  in  the  course  of  heal- 
ing the  important  functions  of  pronation  and  suj^ination  might  be 
lost. 


FRACTURE-DRESSINGS. 


105 


Fractures  of  both  bones  of  tlie  forearm  require  two  straight  sphuts, 
each  of  which  should  be  broader  thau  the  portion  of  the  huib  to 
which  it  is  apphed.  The  anterior  sphnt  extends  from  the  elbow  to 
the  tips  of  the  fingers,  the  posterior  from  the  elbow  to  the  lower 
extremity  of  the  metacarpal  bones.  These  splints  are  carefully 
padded,  the  forearm  is  bent  at  a  right  angle  to  the  arm,  the  frac- 
ture is  reduced,  and  the  splints  are  applied  and  kept  in  place  by 
firm  turns  of  the  roller  bandage.     The  forearm  is  then  slung  across 

Fig.  54. 


Dressing  for  Fractures  of  One  or  Both  Bones  of  the  Forearm. 


the  chest  by  means  of  a  broad  handkerchief,  supporting  it  from  the 
wrist  to  the  elbow.  In  this  dressing  the  hand  should  be  placed 
hetween  pronation  and  supination  ;  that  is,  thumb  up. 

How  are  fractures  of  the  radius  dressed  ? 

Fractures  of  the  nech  of  the  radius,  or  of  the  shaft  just  helow  the 
tubercle,  are  dressed  by  flexing  the  forearm  on  the  arm,  supinating 
the  hand  and  dressing  on  an  anterior   angular  sphnt,  a  compress 


106 


ESSENTIALS  OF  SURGICAL  DRESSING. 


being  applied  to  prevent  foi-ward  projection  of  the  bone.  The 
splint  may  be  moulded  from  pasteboard  or  felt. 

Fractures  of  the  middle  third  of  the  radius  may  be  treated  as 
directed  in  fractures  of  both  bones,  or  by  means  of  the  anterior  rec- 
tangular splint  together  with  a  straight  posterior  splint,  the  latter 
extending  from  the  point  of  the  olecranon  to  the  metacarpo-phalan- 
geal  articulation. 

Fractures  of  the  lower  extreftnity  of  the  radius  are  treated  by  means 
of  a  Bond  splint,  the  Levis  splint,  the  Nekton  splint,  or  the  two 
straight  splints  as  described  for  fractures  of  both  bones.  In  case 
the  Bond  splint  is  applied  two  compresses  are  required,  one  placed 
over  the  lower  fi-agment,  which  has  a  tendency  to  override  pos- 
teriorly, the  other  placed  upon  the  lower  extremity  of  the  upper 

Fig.  55. 


Bond's  Splint. 


fragment.  These  compresses  are  usually  wedge  shaped  and  are 
placed  base  to  base,  the  base  of  the  palmar  compress  being  placed 
upon  the  anterior  surface  of  the  forearm,  just  above  the  seat  of  frac- 
ture, the  base  of  the  dorsal  compress  upon  the  posterior  surface  of 
the  wrist,  just  below  the  seat  of  fracture.  These  compresses  prevent 
the  recurrence  of  the  displacement.  Nearly  all  the  splints  caiTy  the 
hand  towards  the  ulnar  border,  thus  correcting  displacement  to  the 
radial  side,  which  occurs  in  the  fracture.  The  fingers  should  be  left 
free,  and  the  patient  should  be  instructed  to  use  them  from  the  thu-d 
or  fourth  day. 

How  are  fractures  of  the  ulna  dressed  ? 

Fractures  of  the  olecranon  are  treated  by  extending  the  arm,  after 
which  the  centre  of  a  strip  of  adhesive  plaster,  one  inch  wide  and 
two  feet  long,  is  placed  just  above  the  upper  fi-agment,  which  has 


FRACTURE-DRESSINGS.  107 

been  previously  drawn  down  as  far  as  possible.  The  ends  of  this 
strip  are  then  carried  obliquely  downward  and  forward  across  the 
front  of  the  elbow  joint,  and  are  secured  around  the  forearm.  A 
straight  splint  extending  from  just  below  the  axilla  to  the  wrist,  and 
well  padded,  particularly  at  the  position  of  the  elbow  joint,  is  applied 
to  the  anterior  aspect  of  the  arm.  The  thick  layer  of  padding  at  tjie 
elbow  allows  of  very  slight  flexion ;  this  makes  a  much  more  com- 
fortable dressing  than  if  extreme  extension  is  maintained.  In  two 
weeks  passive  motion  should  be  instituted. 

Fractures  of  the  shaft  of  the  ulna  are  dressed  on  two  straight 
splints,  as  when  both  bones  of  the  forearm  are  broken. 

Fractures  of  the  styloid  process  of  the  ulna  are  dressed  on  the  Bond 
splint. 

How  are  fractures  of  the  hand  dressed  ? 

Fractures  of  the  metacarpal  bones  are  treated  by  the  palmar  splint. 
This  extends  from  half  way  up  the  forearm  to  the  extremities  of  the 
fingers,  and  is  as  wide  as  the  hand.  It  should  be  so  padded  that 
when  applied  the  natural  concavity  of  the  palm  is  preserved.  If 
there  is  a  tendency  toward  backward  displacement  of  the  fragments 
this  may  be  corrected  by  a  small  compress. 

Fractures  of  the  finger  are  treated  by  a  straight  posterior  splint 
and  a  moulded  anterior  pasteboard  trough.  The  posterior  splint 
should  extend  from  the  wrist  to  the  extremity  of  the  finger,  the 
anterior  trough  from  the  web  of  the  finger  to  its  extremity. 

How  are  fractures  of  the  femur  dressed? 

Since  these  fractures  are  attended  by  a  great  deal  of  shortening, 
permanent  extension  is  usually  necessary.  This  is  accomplished  by 
means  of  adhesive  plasters.  A  strip  is  cut,  two  and  a  half  inches 
wide,  and  long  enough  to  extend  from  the  upper  end  of  the  lower 
fragment  on  both  sides  of  the  limb,  leaving  a  four-  to  six-inch  loop 
hanging  free  from  below  the  sole  of  the  foot.  In  this  loop  is  placed 
a  piece  of  thin  splint  board,  two  and  half  inches  wide,  and  so  long 
that  when  traction  is  made  the  plaster  will  stand  free  from  the  mal- 
leoli. This  board  is  fastened  in  place,  and  through  a  hole  in  its 
centre  a  cord  or  bandage  is  passed.  One  end  of  the  adhesive  plaster 
is  placed  along  the  inner  aspect  of  the  limb  up  to  the  seat  of  frac- 
ture, the  other  along  the  outer  aspect.     This  plaster  is  secured  in 


108 


ESSENTIALS  OF   SURGICAL  DRESSING. 


place  by  three  or  four  strips  carried  around  the  limb,  and  a  neatly 
applied  spiral  reversed  bandage  of  the  lower  extremity.  After  an 
hour  or  two  the  plaster  is  tightly  adherent.  The  extending  cord  is 
then  passed  over  a  pulley,  a  weight  is  attached,  and  beneath  the 
tendo-Achillis  is  placed  a  pad  of  oakum,  sufficiently  large  to  prevent 


Fig.  56. 


Extension  Applied  for  Fracture  of  the  Femur. 

the  heel  from  bearing  upon  the  mattress.  Counter-extension  is 
provided  by  raising  the  foot  of  the  bed.  Two  sand  bags  are 
applied,  one  to  the  outer  side  of  the  leg,  extending  from  the 
axilla  to  below  the  foot,  the  other  to  the  inner  side,  extending  from 
the  perineum  to  the  level  of  the  sole.    These  bags  are  packed  close 

Fig.  57. 


Dressing  for  Fractured  Femur. 

to  the  leg,  and  are  secured  in  place  by  four  strips,  one  passing 
beneath  the  body,  the  other  three  beneath  the  leg  and  thigh.  These 
strips  are  carried  around  the  sand  bags  and  knotted. 

In  place  of  sand  bags,  bran  bags  and  straight  internal  and  external 
splints,  may  be  employed,     Eversion  of  the  foot  is  prevented  by 


FRACTURE-DRESSINGS.  109 

looping  a  bandage  around  the  metatarsus  and  binding  its  ends  to  the 
internal  sand  bag  ;  or  a  foot-piece  with  a  broad  base  may  be  provided, 
the  latter  resting  upon  a  framework  which  allows  of  sliding  motion. 

Where  there  is  a  tendency  towards  anterior  projection  of  the  upper 
fragment,  this  may  be  prevented  by  a  short  anterior  splint  secured 
to  the  thigh,  or  by  the  application  of  a  shot  bag  to  the  lower  end  of 
the  upper  fragment,  or  by  dressing  the  fracture  on  a  double  inclined 
plane,  extension  being  applied  from  the  knee  in  the  direction  of  the 
long  axis  of  the  femur. 

Fractures  in  the  middle  of  the  shaft  of  the  femur  may  be  kept 
more  securely  in  place  by  supplementing  the  sand-bag  extension  by 
four  short  straight  splints  applied  to  the  anterior,  posterior,  inner 
and  outer  surfaces  of  the  thigh  and  secured  in  place,  either  by  the 
roller  bandage,  or,  what  is  still  better,  by  straps  of  webbing  supplied 
with  buckles.  This  latter  arrangement  allows  of  ready  inspection 
of  the  seat  of  injury.  In  the  dressing  of  all  fractures  of  the  thigh 
and  leg,  the  internal  condyle,  the  internal  malleolus,  and  the  inner 
border  of  the  ball  of  the  great  toe,  should  lie  nearly  in  the  same 
vertical  plane,  the  great  toe  pointing  directly  upward. 

In  impacted  fracture  extension  should  not  be  used. 

Fractures  of  the  lower  extremity  of  the  femvr  are  best  treated  by 
extension  and  the  long  fracture  box,  reaching  upward  to  the  middle 
third  of  the  thigh.  If  there  is  a  marked  tendency  to  backward 
tilting  of  the  lower  fragment  this  may  be  coiTected  by  flexing  the 
knee  and  splinting  in  this  position,  or  by  cutting  the  tendo-Achillis. 

Fracture  of  the  femur  in  infants  is  treated  by  a  carefully  padded 
external  splint  extending  from  the  axilla  to  the  sole  of  the  foot. 
This  is  secured  in  place  by  a  roller  bandage,  which  is  continued  as  a 
spica  of  the  groin  around  the  body,  holding  the  splint  firml}^  in  place. 
Over  this  is  applied  a  plaster  or  silica  bandage.  To  prevent  soiling 
of  this  dressing  It  should  receive  a  coating  of  shellac.  It  should  not 
be  removed  for  four  weeks. 

How  are  fractures  of  the  patella  dressed  ? 

Fractures  of  the  patella  are  treated  by  extending  the  leg,  and 
flexing  the  thigh  upon  the  pelvis  to  an  angle  of  45°.  Next  Is  applied 
a  posterior  straight  splint,  provided  with  lateral  pegs  and  ratchets. 
Strips  of  adhesive  plaster  long  enough  to  extend  from  the  lower 


110  ESSENTIALS   OF  SURGICAL  DRESSING. 

peg  around  the  upper  border  of  tlie  patella  to  the  corresponding 
peg  on  the  opposite  side  of  the  splint,  and  in  a  similar  way  from 
the  ui3per  pegs  around  the  lower  fragment,  are  now  applied  above 
and  below  the  upper  and  lower  fragment  respectively,  being  regularly 
imbricated  toward  the  fracture.  The  extremities  of  these  straps  are 
fastened  to  the  pegs  by  turning  the  latter  ;  the  lower  fragment  is  first 
steadied,  then  the  upper  fragment  is  drawn  down  into  position. 

If  the  edges  of  the  fragments  tilt  forward  this  is  corrected  by  the 
pressure  of  a  piece  of  strapping  carried  transversely  around  the  limb. 

If  there  is  great  swelling,  with  marked  effusion  into  the  joint,  the 
latter  should  be  aspirated  before  this  dressing  is  employed  ;  or  if  this 
is  not  deemed  advisable  the  inflammation  may  be  combated  by  rest, 
elevation,  moderate  pressure,  and  cooling  and  evaporating  lotions. 
The  splint  should  be  worn  for  eight  weeks.  It  should  be  followed 
by  a  plaster  dressing  continued  for  two  or  three  months. 

Fig.  58. 


C.LENTZIi&SONS      'WH 


Fracture- Box. 

How  are  fractures  of  the  leg  dressed  ? 

All  these  fractures  may  be  treated  in  the  fracture-box,  applying 
lateral  compresses  to  correct  deformity,  and  using  extension  if  there 
is  marked  shortening.  The  fracture-box  should  fix  the  knee-joint, 
should  be  strong,  and  should  hold  the  leg  in  such  a  position  that  the 
inner  borders  of  the  internal  condyle,  the  internal  malleolus  and  the 
ball  of  the  great  toe  lie  in  the  same  vertical  plane,  and  the  foot  is 
kept  nearly  at  right  angles  to  the  leg,  pressure  being  taken  off  the 
heel  by  a  pad  of  oakum  beneath  the  tendo-Achillis.  For  very  marked 
displacement  and  difiiculty  in  retention,  the  hip  and  knee  may  be 
flexed,  and  the  limb  may  be  laid  on  its  outer  side  and  bound  to  a 
double-angled  external  splint  for  a  few  days,  after  which  it  may  be 
placed  in  the  fracture-box. 

The  fracture-box  consists  of  a  posterior  splint,  with  a  foot-piece 


LUXATIONS.  Ill 

and  hinged  sides  ;  a  pillow  is  placed  in  the  box,  the  leg  U  placed  on 
the  pillow,  and  the  sides  are  brought  up  and  tied. 

External,  posterior,  anterior,  and  straight  moulded  splints  may 
also  be  used  for  these  fractures. 

Pott's  fracture  may  be  treated  by  the  application  of  Dupuytrens 
splint.  This  consists  of  a  straight  internal  splint,  notched  at  the 
lower  end,  and  extending  from  the  head  of  the  tibia  to  a  point  four 
inches  below  the  side  of  the  foot.  The  upper  part  of  the  splint  is 
fastened  to  the  inner  surface  of  the  leg,  a  thick  pad,  not  extending 
below  the  internal  malleolus,  is  applied  to  the  lower  portion,  and  the 
foot  is  drawn  close  to  the  splint,  in  the  space  beneath  the  pad,  by  a 
figure-of-eight,  so  applied  that  there  are  no  turns  which  make  pres- 
sure above  the  external  malleolus  ;  the  knee  is  then  bent,  and  the 
leg  is  suspended,  or  is  laid  on  its  outer  side. 

Fig.  59. 


Dupuytren's  Splint  Applied. 

How  are  fractures  of  the  foot  treated  ? 

Fractures  of  the  foot  are  treated  by  the  fracture-box  and  evapora- 
tive lotions  until  acute  inflammation  has  subsided,  after  which  a 
fixed  dressing  should  be  applied. 


LUXATIONS. 

What  are  the  general  principles  concerning  the  treatment  of 
luxations  ? 

1 .  The  displacement  should  be  reduced  immediately. 

2.  Reduction  should  be  effected  by  manipulation  when  possible. 
This  consists  in  overcoming  the  obstacles  to  replacement  by  relaxing 
muscles,  relieving  from  tension  tendons  and  ligaments,  and  utilizing 
the  mechanical  arrangement  of  the  joint  to  sweep  the  displaced 
portion  of  the  articulation  over  or  around  bony  prominences,  into 
proper  position. 


112  ESSENTIALS   OF  SDHGICAL  DRESSING. 

3.  Muscular  resistance  sliould  be  overcome  by  etber,  pushed  to  full 
surgical  anesthesia. 

4.  The  surgeon  must  not  leave  the  patient  till  he  is  certain  that 
reduction  is  complete. 

5.  After  reduction  the  joint  should  be  splinted,  and  the  inflamma- 
tion should  be  controlled  b}''  cooling  and  evaporating  lotions,  supi)le- 
mented,  in  three  days,  by  massage. 

6.  A  displaced  joint  is  permanently  weakened.  It  should  be  sup- 
ported for  a  long  time  after  apparent  recovery. 

How  are  luxations  of  the  lower  jaw  reduced? 

The  patient  is  seated  upon  a  low  chair  or  a  stool ;  the  surgeon, 
standing  in  front,  places  his  thumbs  upon  the  last  molar  teeth  of 
each  side  of  the  lower  jaw,  while  the  fingers  are  placed  beneath  the 
chin  ;  by  a  sudden  pressure  downward  with  the  thumbs,  while  the 
fingers  at  the  same  time  press  the  front  of  the  chin  up,  the  head  of 
the  bone  is  forced  out  of  the  zygomatic  fossa,  and  is  pulled  in  place 
by  the  external  pterygoid,  masseter,  and  the  temporal  muscles. 
The  thumbs  should  be  withdrawn  from  between  the  teeth  the  moment 
the  bone  is  felt  slipping  into  place,  as  otherwise  they  may  be  severely 
bitten  ;  they  should  also  be  protected  by  wrapping  them  with  band- 
ages. Luxations  of  the  lower  jaw  may  also  be  reduced  by  inserting 
wedges  between  the  molar  teeth  of  the  lower  and  upper  jaws  on  each 
side.  On  pressing  the  point  of  the  chin  directly  upward  these 
wedges  act  as  a  fulcrum,  and  the  head  of  the  bone  can  easily  be 
forced  into  its  proper  position.  After  reduction  a  Barton  bandage 
should  be  worn  for  a  few  days. 

How  are  luxations  of  the  shoulder  joint  reduced? 

Reduction  of  the  shoulder  joint  may  be  effected  by  several 
methods : — 

1 .   The  heel  in  the  axiUa. 

The  patient  is  placed  fiat  upon  his  back  ;  the  surgeon  seats  him- 
self facing  the  patient,  and  close  by  the  hip  of  the  injured  side.  He 
then  i^laces  his  unbooted  heel  in  the  axilla,  seizes  the  wrist  and  makes 
firm  and  steady  traction.  It  is  better  to  make  extension  from  the 
lower  extremity  of  the  humerus ;  this  may  be  accomplished  by 
folding  a  sheet  and  throwing  a  clove-hitch  around  the  humerus  at 
this  point. 


LUXATIONS. 


113 


2.  The  heel  upon  the  shoulder. 

The  patient  is  placed  flat  upon  Ms  back  as  before ;  tbe  surgeon 
seats  himself  beyond  the  patient's  head,  places  his  unbooted  heel 
upon  the  top  of  the  shoulder,  seizes  the  wrist  and  makes  firm  trac- 
tion upward  in  the  direction  of  the  long  axis  of  the  body. 

3.  The  crutch  lever. 

The  arm  is  flexed  upon  the  forearm  and  carried  out  from  the  body. 
The  well-padded  head  of  a  crutch,  long  enough  to  rest  upon  the  floor, 
is  fitted  into  the  axilla ;  the  patient  then  throws  his  weight  on  this 
cruteh  while  the  arm  is  forced  down  to  the  side  by  the  surgeon. 

Manipulation. — The  patient  is   placed  flat  upon  his  back,  the 

Fig.  60. 


Eeduction  by  Extension. 


forearm  is  flexed  upon  the  arm,  and  the  arm  is  carried  out  from  the 
side  until  the  elbow  is  raised  above  the  level  of  the  shoulders.  Using 
the  forearm  as  a  lever,  the  humerus  is  then  rotated  outward  as 
far  as  possible.  The  surgeon  seizes  with  his  right  hand  the  fore- 
arm just  below  the  bend  of  the  elbow,  makes  pressure  with  the 
fingers  of  the  other  hand  upon  the  head  of  the  bone,  brings  the 
arm  down  to  the  side,  and  rotates  it  inward,  carrying  the  forearm 
across  the  chest.  Or  an  assistant  places  his  fist  in  the  axilla  and  the 
arm  is  swept  down  to  the  side  and  rotated  inward  as  before. 

Kocher's  Method. — The   forearm  is  flexed  upon  the   arm,  and 
the  latter  is  brought  in  close  contact  to  the  thorax  in  the  axillary 
line.     By  means  of  the  flexed  forearm  as  a  lever  the  humerus  is 
8 


114 


ESSENTIALS   OP  SURGICAL  DRESSING. 


carried  into  extreme  external  rotation  ;  the  arm  is  then  forced  for- 
ward and  upward,  rotated  inward  as  far  as  possible,  and  circumducted 
over  the  fi'ont  of  the  chest. 

Fig.  61. 


Kocher's  Method— First  Movement. 


The  hackward  luxation,  of  the  humerus  may  frequently  be  reduced 
by  flexing  the  forearm  on  the  arm,  canying  the  arm  out  from  the 


Fig.  62. 


Kocher's  Method— Second  Movement. 


side  till  the  deltoid  muscle  is  thoroughly  relaxed,  and  pushing  the 
bone  into  place  b}^  pressure  of  the  thumb. 

The  after  treatment  of  shoulder  luxations  consists  in  the  applica- 
tion of  a  Yelpeau  or  Desault  bandage  together  with  cooling  lotions. 


LUXATIONS. 


115 


After  one  or  two  weeks  the  bandage  is  removed.     The  joint  may 
subsequently  be  supported  by  means  of  a  spica  of  the  shoulder. 

How  are  luxations  of  the  elbow  joint  reduced? 

Luxations  of  the  elbow  joint  may  be  reduced  by  extreme  exten- 
sion, followed  by  rapid  flexion ;  or  the  knee  of  the  surgeon  may 
be  placed  in  the  bend  of  the  elbow  and  the  forearm  forcibly  flexed 
over  this  as  a  fulcrum.  Unless  the  joint  can  be  flexed  to  an  acute 
angle  the  surgeon  cannot  feel  assured  that  reduction  has  been  ac- 
complished, 

Wliert,  the  radius  alone  is  luxated  the  forearm  should  be  flexed 

Fig.  63. 


Keduction  of  Elbow  Joint  Luxation. 


and  the  hand  should  be  supiuated  if  the  head  of  the  bone  is  in  front 
of  the  external  condyle,  or  pronated  if  the  displacement  is  posterior 
to  this  bony  projection.  The  head  of  the  bone  can  then  usually  be 
pressed  into  place.  In  dressing  luxations  of  the  radius  alone  a  pad 
is  required  since  the  luxation  has  a  marked  tendency  to  recur. 

An  anterior  angular  splint  should  be  applied  in  the  after  treat- 
ment of  all  luxations  about  the  elbow  joint,  and  passive  motion 
should  be  instituted  as  soon  as  inflammatory  symptoms  subside. 

How  are  luxations  of  the  wrist  joint  treated'? 

Fostei'ior  displacement  of  the  carpal  bones  is  treated  by  flexing 


lU 


ESSENTIALS  OF  SURGICAL  DRESSING. 


the  hand,  pressing  tlie  carpus  forward,  and  suddenly  extending  the 
hand  on  the  first  sign  of  the  bone  shpping  into  place. 

The  anterior  displacement  is  treated  by  extending  the  hand, 
13ressing  the  carpus  backward,  and  suddenly  flexing  the  hand  on  the 
first  sign  of  the  bone  slipping  into  place. 

Reduction  may  also  be  accomplished  bj^  extension  and  counter-ex- 
tension. 

How  are  luxations  of  the  bones  of  the  hand  treated? 

Luxations  of  the  metacarpus  are  treated  by  extension  and  direct 
pressure,  after  which  a  palmar  splint  is  applied. 

Fig.  64. 


Manipulation  for  Reduction  of  Backward  Luxation. 


Reduction  of  the  jyhalanx  may  be  accomplished  by  traction ;  or  by 
forcing  the  finger  into  extreme  extension  when  the  bony  prominences 
are  unlocked  and  the  phalanx  sHps  into  place. 

Bachicard  luxation  of  the  first  phalanx  on  the  metacarpcd  hone 
of  the  thumb  is  at  times  \QYy  difficult  to  reduce.  The  metacarpal 
bone  of  the  thumb  should  be  forcibly  adducted  into  the  palm  of  the 
hand.  The  phalanx  should  then  be  extended  far  backward  until 
the  thumb  nail  nearlj''  touches  the  first  jDhalanx  or  the  metacarpal 
bone  of  the  thumb  at  the  wrist,  when  it  is  then  suddenly  flexed, 
the  thumb  of  the  surgeon  at  the  same  time  pressing  its  proximal 


LUXATIONS. 


117 


extremity  into  position.     If  this  method  fails  one  or  both  tendons 
of  the  flexor  brevis  polhcis  should  be  cut. 

How  are  luxations  of  the  hip  joint  treated  ? 

Baclncard  luxations  are  treated  by  first  flexing  the  leg  on  the  thigh 
and  the  thigh  on  the  abdomen,  and  carrying  the  knee  of  the  affected 
side  somewhat  toward  the  opposite  side  of  the  body.  While  flexion 
is  still  maintained  the  thigh  is  circumducted,  or  swept  outward  ;  at 
the  same  time  the  foot  is  rotated  outward  and  the  leg  is  brought 
quickly  down  to  an  extended  position  by  the  side  of  its  fellow. 

Fig.  65. 


Manipulation  for  Reduction  of  Forward  Luxation. 


Foncard  luxations  are  treated  by  flexing  the  leg  on  the  thigh  and 
the  thigh  on  the  abdomen,  at  the  same  time  abducting  or  carrying 
the  limb  away  from  the  body  ;  it  is  then  circumducted  or  swept  in- 
ward, carrying  the  thigh  over  the  body  and  making  internal  rotation, 
and  is  quickly  brought  down  by  the  side  of  its  fellow. 

After  reduction  the  knees  should  be  bandaged  together  for  a  week, 
after  which  passive  motion  is  instituted.  The  patient  should  wear 
a  moulded  support  for  several  months. 

How  are  luxations  of  the  knee  joint  reduced? 

The  thigh  is  flexed  upon  the  abdomen  ;  then  by  means  of  trac- 
tion and  direct  pressure  the  bone  may  readily  be  forced  into  place. 


118  ESSENTIALS  OF  SURGICAL  DRESSING. 

After  reduction  the  joint  should  be  spKnted  until  the  subsidence  of 
inflammation,  when  passive  motion  should  be  instituted.  The  patient 
should  wear  a  knee-cap  for  many  months. 

How  are  luxations  of  the  patella  reduced? 

In  reducing  lateral  luxations  the  leg  is  extended  upon  the  thigh 
and  the  thigh  is  flexed  upon  the  abdomen ,  The  margin  of  the 
patella  furthest  removed  from  the  joint  is  then  forcibly  depressed. 
This  tilts  up  and  frees  its  inner  border,  and  the  bone  is  at  once 
snapped  into  place  by  the  quadriceps. 

Eotary  luxation  of  the  patella  is  reduced  by  ahernate  flgxion  and 
extension  or  by  direct  pressure. 

How  are  luxations  of  the  semilunar  cartilages  reduced  ? 

By  forced  flexion,  followed  by  sudden  extension.  A  knee-cap 
should  be  worn  for  one  or  two  years. 

How  are  luxations  of  the  ankle  joint  reduced? 

The  leg  is  flexed  on  the  thigh  and  the  foot  is  moderately  extended, 
to  relax  muscles.  Extension  is  then  applied  to  the  foot  and  counter- 
extension  to  the  thigh,  when  by  manipulation  and  pressure  the 
bones  can  usually  be  restored  to  their  proper  position.  The  after 
treatment  consists  in  the  subduing  of  inflammation  and  the  apjDlica- 
tion  of  a  plaster  bandage. 

Luxations  of  the  tarsal  bones  are  reduced  by  extension,  counter- 
extension  and  direct  pressure.  If  this  fails  the  tenotome  must  be 
used  freely. 


VENEREAL  DISEASES. 

Chancroid. 

What  is  a  chancroid  ? 

A  chancroid  is  an  ulcer  caused  by  contact  with  the  secretions  of  a 
similar  ulcer. 

"What  are  the  characteristics  of  a  chancroid  ? 

It  has  no  distinct  period  of  incubation.  It  may  develop  in  twenty- 
four  hours,  though  it  usually  appears  in  frum  three  to  five  days 
after  contagion. 


CHANCROID.  119 

A  papule  first  appears  ;  this  becomes  a  vesicle,  a  pustule,  and 
shortly  an  ulcer. 

It  is  frequently  multiple^  causing  the  appearance  of  other  sores 
upon  surfaces  with  which  it  comes  into  contact. 

It  is  distinctly  inflammatory  in  type  ;  the  edges  are  punched  out, 
irregular,  and  frequently  undermined ;  the  discharge  is  abundant, 
the  surface  is  covered  by  a  tough,  gray,  adherent  slough. 

It  is  auto-inocidahle ;  that  is,  the  secretions  inoculated  upon 
another  part  of  the  body  will  produce  a  similar  sore. 

It  is  not  indurated^  and  the  parts  surrounding  are  no  harder  than 
is  common  to  any  other  inflammation  of  equal  severity. 

It  has  no  distinct  tendency  toward  spontaneous  cure. 

It  produces  mono-ganglionic^  unilateral  lymphatic  enlargement  in 
the  groin;  that  is,  there  is  a  single  bubo  on  one  side  of  the  body. 
If  the  ulcer  attacks  the  frsenum  there  may  be  bilateral  lymphatic 
involvement. 

As  a  consequence  of  chancroid  there  may  be  simple  inflammatory 
biiho^  which  usually  undergoes  spontaneous  resolution,  or,  if  it 
suppurates,  discharges  laudable  pus  and  readily  heals,  or  virulent 
chancroidal  huho,  which  exhibits  all  the  characteristics  of  the 
original  sore. 

The  chancroid  is  not  followed  by  secondary  eruptions. 

What  is  the  favorite  seat  of  chancroid  ? 

Chancroids  may  be  found  on  any  part  of  the  body,  but  they  are 
usually  placed  about  the  genitalia.  In  this  region  they  commonly 
appear  about  the  fraenum,  though  they  may  be  found  on  the  pre- 
puce, the  glans,  the  meatus,  or  any  other  portions  of  the  organs. 

How  may  the  chancroid  be  complicated  ? 

By  htflammation.  This  complication  may  occur  from  mechanical 
irritation,  from  excess,  or  from  improper  dressing.  It  is  denoted  by 
swelling,  pain,  blood-stained  secretion,  and  rapid  extension.  The 
ulcer  shows  a  marked  tendency  to  undermine  the  skin,  and  buboes 
very  commonly  accompany  this  complication. 

By  sloughing  or  phagedena.  Constitutional  debility  predisposes 
to  this  complication.  It  is  characterized  by  the  phenomena  of 
inflammation,  together  with  rapid  and  extensive  destruction  of  tis- 


120  ESSENTIALS   OF  SURGICAL  DRESSING. 

sue.  There  is  usually  much  jDain,  and  violent  hemorrhages  may 
occur. 

By  serpiginous  ulceration.  This  is  attended  by  very  slight  con- 
stitutional disturbance.  The  process  slowly  but  steadily  extends, 
undermining  the  surrounding  healthy  skin ;  the  edges  are  uneven 
and  sharply  cut ;  the  discharge  is  thin  and  sanious. 

Bi/  phimosis  and  paraphimosis.  These  conditions  may  prove 
serious  complications,  since  in  the  one  case  it  is  difficult  to  reach  the 
ulcer  and  apply  the  proper  treatment,  in  the  other  the  resulting 
congestion  is  so  great  as  to  markedly  increase  the  inflammatory 
phenomena. 

With  what  other  ulcerations  may  the  chancroid  be  con- 
founded ? 

With  herpes,  with  chancre,  with  other  forms  of  syphilitic  erup- 
tion, or  with  the  excoriated  form  of  balanitis. 

How  is  a  chancroid  disting-uished  from  a  chancre  ? 

While  the  chancroid  develops  at  once  after  exposure  to  contagion, 
the  chancre  has  a  period  of  incubation  varying  from  two  to  three 
weeks  ;  moreover,  the  chancre  is  generally  single,  is  apparently  non- 
inflammatory in  type,  giving  usually  a  scanty  secretion.  It  is  fol- 
lowed by  a  polyganglionic,  bilateral,  lymphatic  involvement,  these 
buboes  almost  never  suppurating.  It  is  not  auto-inoculable,  it  is  dis- 
tinctly indurated,  and  is  followed  by  secondary  eruptions. 

In  spite  of  the  marked  diflerence  between  typical  examples  of 
the  two  afi"ections,  sores  will  be  encountered  in  which  it  is  impossible 
to  say  whether  the  principal  features  belong  mainly  to  syphilis,  or  to 
the  chancroid  as  a  local  venereal  ulcer.  In  these  cases  the  test  is 
afl'orded  by  inoculation.  If,  on  inoculating  the  patient  with  pus  of  ■ 
this  ulcer,  a  chancroid  is  produced,  it  can  be  said  with  certainty  that 
the  initial  lesion  is  a  simple  venereal  sore  or  chancroid.  The  pre- 
ferable positions  for  inoculation  are  either  beneath  the  nipple  or  on 
the  outer  surfaces  of  the  thigh,  since  in  these  regions  the  sore  runs 
a  mild  course  and  is  not  hable  to  be  followed  by  chancroidal  bubo. 

In  chancroid  within  the  urethra  this  is  a  valuable  mode  of  diagno- 
sis ;  also  in  cases  of  marked  phimosis  accompanied  by  symptoms 
presumably  chancroidal,  auto-inoculation  will  enable  the  surgeon  to 
arrive  at  a  reliable  conclusion.     It  must  be  borne  in  mind  that  the 


CHANCROID.  121 

fact  of  auto-inoculation  succeeding  simply  shows  that  the  sore  is  a 
chancroid,  and  does  not  exclude  the  possibility  of  syphilis  subse- 
quently developing,  since  it  is  perfectly  possible  for  the  contagious 
matter  of  both  diseases  to  be  received  at  the  same  time. 

What  conditions  predispose  to  the  development  of  a  chan- 
croid ? 
The  presence  of  abrasions  or  ulcerations,  a  redundant  prepuce, 
lack  of  local  cleanhness. 

How  are  chancroids  treated  ? 

Since  the  danger  of  rapidly  destructive  inflammation  attacking 
chancroids  is  never  absent  until  they  are  completely  cicatrized, 
since  even  the  most  superficial  sores  preserve  the  virulent  character- 
istics of  the  most  marked  ulcerations,  and  may  at  any  time  be  fol- 
lowed by  the  simple  or  chancroidal  bubo,  the  most  satisfactory 
method  of  treatment  consists  in  the  immediate  destruction  of  the 
entire  ulcerated  surface,  thus  substituting  healthy  granulation  for  a 
chancroidal  ulcer.  This  is  most  readily  accomplished  by  means  of  the 
hot  iron,  or  by  sulphuric  or  nitric  acid.  The  im]3ortant  point  in  this 
treatment  is  to  thoroughly  destroy  eveiy  portion  of  the  ulcer,  since 
the  most  minute  part  left  untreated  will  re-inoculate  the  enthe 
granulating  surface. 

The  hot  iron  is  to  be  preferred  to  other  cauterants.  The  ulcera- 
tion frequently  undermines  the  skin,  extending  sometimes  to  the 
depth  of  one  or  two  inches  beneath  what  appears  to  be  a  per- 
fectly healthy  surface.  Every  sinus  and  recess  must  be  acted 
upon  by  the  cauterant,  even  at  the  sacrifice  of  a  great  deal  of 
tissue.  As  a  dressing  a  few  layers  of  dry  antiseptic  gauze  can 
be  applied  to  the  burned  surface.  On  separation  of  the  eschar 
a  healthy  ulceration  is  left,  which  heals  under  cleanliness,  protec- 
tion, and  the  application  of  the  ordinary  dusting  powders.  "Where 
the  cautery  is  objected  to,  nitric  acid  may  be  used.  The  pain  of  this 
application  may  be  blunted  by  the  use  of  a  few  drops  of  a  20  per 
cent,  solution  of  cocaine.  This  is  applied  to  the  surface  of  the  ulcer ; 
the  latter  is  then  dried  by  absorbent  cotton,  and  the  acid  is  applied 
by  means  of  a  glass  rod.  Subsequent  dressing  is  the  same  as  after 
the  actual  cautery. 

A  very  convenient  way  of  burning  chancroids  consists  in  the  appli- 


122  ESSENTIALS   OF  SURGICAL  DRESSING. 

catiou  of  a  plaster  made  by  pouring  concentrated  sulphuric  acid 
upon  pulverized  charcoal  until  a  mixture  of  about  the  consistency  of 
molasses  is  made.  The  chancroid  is  cleaned  carefully,  dried  as  far 
as  possible,  and  this  paste  is  packed  into  every  recess.  The  advan- 
tage of  this  dressing  lies  in  the  fact  that  the  acid  shortly  evaporates 
or  is  neutralized,  thus  leaving  a  charcoal  dressing  to  cover  the 
ulceration.  By  the  time  this  drops  oJ0F  cicatrization  is  commonly 
well  advanced. 

Where  there  is  objection  to  any  form  of  cauterization  milder  meas- 
ures may  be  employed,  and  these  are  in  the  great  majority  of  cases 
successful,  especially  where  the  sore  has  invaded  healthy  tissues  and 
the  patient  is  obedient  to  medical  direction.  The  most  satisfactory 
palliative  treatment  consists  in  washing  the  sores  three  times  a  day 
in  a  nitric  acid  solution,  made  by  adding  a  drachm  of  strong  nitric 
acid  to  a  pint  of  water.  The  surface  of  the  sore  is  then  dusted  with 
iodoform,  to  each  drachm  of  which  has  been  added  two  drops  of 
attar  of  roses,  or  with  zinc  oxide,  bismuth  subnitrate,  or  calomel. 

Where  discharge  is  profuse,  daily  S]oraying  with  peroxide  of 
hydrogen,  full  strength,  will  be  found  serviceable. 

If  the  chancroid  becomes  complicated  by  inflammation,  in  addition 
to  the  constitutional  treatment  suitable  to  inflammation,  evaporat- 
ing lotions  will  be  found  of  service.  Alcohol  and  dilute  lead 
water,  equal  parts,  may  be  applied,  a  piece  of  lint  being  wrung 
out  in  this  solution  and  placed  about  the  inflamed  parts ;  this 
lint  should  be  kept  constantly  wet.  Soaking  the  chancroid  in 
exceedingly  hot  water  many  times  during  the  day  is  often  of 
service,  the  dressing  during  the  intervals  of  this  treatment  con- 
sisting of  many  layers  of  gauze  wrung  out  in  1-10,000  bichloride 
solution  and  surrounded  with  waxed  jDaper  or  other  impervious 
material: 

If  the  ulcer  becomes  phagedenic^  a  general  tonic  and  stimulating 
systemic  treatment  is  indicated.  If  the  sloughing  process  is  extend- 
ing very  rapidly,  threatening  great  destruction  of  tissue,  the  actual 
cautery  should  be  used  unsparingly.  Prolonged  warm  baths  con- 
tinued for  hours,  or  even  days,  are  at  times  attended  by  most  happy 
results. 

Serpiginous  ulceration  is  exceedingly  resistant  to  all  treatment ; 
the  constitution  is  usually  at  fault,  and  every  effort  should  be  made 


CHANCROID.  123 

to  build  up  the  general  health.  Beyond  the  actual  cautery  and  pro- 
longed warm  baths,  local  treatment  seems  to  be  of  httle  avail. 

The  simple  wflammatory  huho  is  treated  by  rest,  counter-kritation 
around  the  focus  of  swelling,  and  pressure.  Pressure  may  be  applied 
by  means  of  a  compress  and  spica  bandage,  or,  if  the  patient  is  con- 
fined to  bed,  by  means  of  a  shot  bag  or  sand  bag  placed  over  the 
inflamed  part.  Threatening  suppuration  can  sometimes  be  aborted 
by  the  injection  of  10  to  20  minims  of  a  5  per  cent,  solution  of  car- 
bolic acid  into  the  centre  of  the  gland.  When  fluctuation  is  detected 
a  free  opening  should  be  made ;  laudable  pus  escapes  and  the 
abscess  heals  kindly. 

Until  it  is  evacuated  the  virulent  huho  cannot  be  diagnosed  from 
that  due  to  simple  inflammation,  and  the  same  treatment  is  appli- 
cable as  in  the  first  instance.  If  on  incising  the  sweUing  a  thin, 
sanious  pus  is  discharged  and  the  incision  steadily  enlarges,  being 
attacked  by  the  characteristic  chancroidal  ulceration,  the  treatment 
is  the  same  as  in  the  case  of  a  chancroid.  Repeated  washings  with 
carbolic  lotion,  or  a  weak  nitric  acid  solution,  followed  by  a  liberal 
application  of  iodoform,  may  be  tried.  If  the  ulceration  steadily 
extends,  every  sinus  and  recess  must  be  slit  up,  all  sloughs  removed 
by  the  curette,  and  the  whole  surface  thoroughly  cauterized,  prefer- 
ably by  nitric  or  carbolic  acid. 

Where  phimosis  complicates  the  chancroid,  the  discharge  must  be 
kept  constantly  washed  away  by  repeated  injections  of  warm  water, 
followed  by  one  or  two  syringefnls  of  dilute  carbolic  solution,  dilute 
nitrate  of  silver  solution,  4grs.  to  the  ounce,  or  the  nitric  acid  lotion. 
If  pain,  swelling  and  discharge  denote  a  rapid  increase  of  trouble, 
the  prepuce  should  at  once  be  slit  up,  and  the  chancroid  scraped  and 
cauterized.  The  cauterant  should  also  be  applied  to  the  edges  of 
the  incision. 

If  paraphimosis  complicates  the  chancroid,  cooling  and  evaporat- 
ing lotions  are  indicated,  unless  there  is  a  sufficient  degree  of  con- 
striction present  to  threaten  gangrene.  When  reduction  cannot  be 
efl"ected  in  other  ways,  incision  of  the  constricting  ring  of  tissue 
will  be  required. 


124  ESSENTIALS   OF   SURGICAL  DRESSING. 

Gonorrhoea. 

Describe  the  urethra. 

The  urethra  varies  in  length  from  eight  to  nine  inches.  It  con- 
sists of  three  portions,  spongy^  membranous,  and  the  prostatic. 

The  spongy  portion  extends  from  the  meatus  to  the  anterior  layer 
of  the  triangular  ligament,  and  is  about  six  inches  in  length.  The 
meatus  is  the  narrowest  portion  of  the  urethra.  One  and  one-half 
inches  posterior  to  it  is  the  lacuna  magna,  a  large  mucous  follicle 
placed  on  the  upper  surface  of  the  urethra  with  its  opening  dhected 
forward.  In  this  follicle  small  instruments  may  readily  catch  unless 
their  points  are  kept  along  the  floor  of  the  urethra.  The  bulbous 
portion  of  the  urethi-a  lies  just  in  front  of  the  anterior  layer  of  the 
triangular  ligament.  At  this  point  the  canal  is  considerably  dilated. 
This  is  the  widest  and  most  dilatable  portion  of  the  whole  urethra. 

The  membranous  portion  of  the  urethra  is  that  part  of  the  tube 
which  lies  between  the  anterior  and  the  posterior  layers  of  the  tri- 
angular ligament.  It  is  about  three-quarters  of  an  inch  in  length, 
and  is  placed  one  inch  below  the  pubic  arch.  It  is  cj^lindrical  in 
shape,  and,  excepting  the  meatus,  the  narrowest  part  of  the  urethra. 
It  is  suiTounded  by  the  compressor-urethrae  muscle. 

The  prostatic  portion  of  the  urethra  is  about  one  and  a  quarter 
inches  long.  It  passes  through  the  upper  portion  of  the  prostate, 
gland. 

The  urethra  is  further  divided  into  an  anterior  2indi posten'ior  pai^t. 

The  anterior  part  is  that  portion  external  to  the  anterior  layer  of 
the  triangular  ligament.     It  is  surrounded  by  erectile  tissue. 

The  posterior  part  includes  the  membranous  and  prostatic  urethra, 
and  is  enveloped  in  a  thick  layer  of  strong  muscular  tissue.  The 
compressor-urethrge  muscle  surrounding  the  membranous  portion  of 
the  urethra  is  readily  excited  to  reflex  spasm  ;  hence,  fluids  injected 
into  the  urethra  rarely  reach  further  than  this  point,  and  discharges 
occurring  within  or  behind  the  membranous  urethra  are  more  prone 
to  flow  into  the  bladder  than  to  escape  externallj^ 

What  is  gonorrhoea  ? 

Gonorrhoea  is  a  contagious  specific  inflammation  afi"ecting  mucous 
membranes,  particularly  those  of  the  genito-urinary  tract. 


GONORRHOEA.  125 

What  is  the  cause  of  gonorrhoea  ? 

The  gonococcus  introduced  into  the  urethra.  The  contagion  may 
be  mediate  or  immediate.  Immediate  by  means  of  direct  personal 
contact ;  mediate  through  the  medium  of  clothing  or  other  articles 
containing  the  specific  microorganism. 

A  non-specific  urethritis  may  develop  from  contact  with  foul  aud 
irritating  discharges ;  this  ordinarily  undergoes  spontaneous  resolu- 
tion in  a  few  days.  Gronorrhoea  begins  in  the  male  usually  in  the 
fossa  navicularis  and  passes  backward.  In  the  female  it  commonly 
begins  in  the  urethra  or  in  the  cervix,  though  vulvitis  and  vaginitis 
are  frequently  the  first  conditions  observed  by  the  surgeon. 

What  are  the  symptoms  of  gonorrhoea  ? 

In  from  three  to  five  days  after  exposure  to  contagion  a  tickling 
sensation  is  noticed  at  the  meatus ;  this  is  shortly  changed  to  a 
burning,  noticed  particularly  during  urination.  On  examination  the 
lips  are  somewhat  reddened  and  everted,  and  there  is  a  slight  muco- 
purulent discharge ;  this  discharge  rapidly  increases.  The  ardor 
urin^e  becomes  intense  ;  there  is  a  proftise  flow  of  pus  ;  painful  erec- 
tions occur  during  the  night,  and  the  patient  is  compelled  to  urinate 
frequently. 

These  symptoms  continue  for  fi'om  foui'teen  to  twenty  days,  the 
inflammation  in  the  meantime  having  extended  back  to  the  bulb, 
as  denoted  by  a  feeling  of  fullness  and  heat  in  the  perineum.  At 
about  the  end  of  the  third  week  the  symptoms  rapidly  subside,  the 
discharge  becomes  scanty  and  mucous  in  character  until  it  is  finally 
reduced  to  a  drop,  which  is  noticed  in  the  morning  as  glueing  the 
lips  of  the  meatus  together.  If  the  case  runs  a  favorable  course 
this  disappears,  and  in  about  six  weeks  from  the  beginning  of  the 
attack  recovery  is  complete.  The  disease,  however,  may  extend 
back  to  the  posterior  part  of  the  urethra  and  assume  a  chronic  form. 
Extension  of  the  disease  to  the  posterior  urethra  rarely  takes  place 
before  the  third  week.  The  extension  may  be  accompanied  by  no 
subjective  symptoms,  or  may  be  denoted  by  vesical  tenesmus,  by 
haematuria,  by  burning  or  lancinating  pains  in  the  deeper  part  of  the 
perineum,  exacerbated  by  micturition  and  defecation,  and  by  frequent 
pollutions  accompanied  by  pain  in  the  deep  urethra.     The  discharge 


126  ESSENTIALS  OF  SUEGICAL  DRESSING. 

is  similar  to  that  of  anterior  urethritis.     It  does  not  appear  at  the 
meatus,  however,  but  passes  back  into  the  bladder. 

What  are  the  stages  of  acute  anterior  urethritis  ? 

(1)  Increasing  stage. 

(2)  Stationary  stage. 

(3)  Subsiding  stage. 

What  are  the  symptoms  of  the  increasing"  stage  ? 

Ardor  uringe  ;  purulent  discharge,  increasing  in  quantity  ;  painful 
erections ;  frequent  urination,  the  stream  passed  being  small,  forked 
and  irregular.  These  sjniiptoms  maj^  in  individual  eases,  be  present 
in  all  degrees  of  severity. 

What  are  the  complications  of  the  first  stage  ? 

Balanitis  and  Posthitis.  Inflammation  extending  over  the  mucous 
layer  of  the  glans  joenis  and  the  foreskin. 

Phimosis^  or  inability  to  retract  the  foreskin,  usually  due  to  oede- 
matous  swelling. 

Paraphimosis.,  or  inability  to  draw  the  retracted  forcvskin  forward. 

What  are  the  symptoms  and  complications  of  the  second  or 
stationary  stage  of  acute  gonorrhoea  ? 

The  inflammation  gradually  extends  backward.  The  symptoms 
of  the  first  stage  continue,  alternating  in  severity  from  day  to  day. 
The  following  complications  may  be  developed  : — 

FoIliaiJar  Abscesses.  These  appear  as  small,  round,  tender  tumors 
along  the  floor  of  the  urethra.  They  may  evacuate  their  contents 
either  into  the  urethra  or  externally. 

Periurethral  Abscesses.  These  are  most  commonly  found  about  the 
fossa  navicularis  or  the  bulbous  portion  of  the  urethra,  where  the 
disease  is  most  persistent. 

Lymphangitis.  This  is  commonly  due  to  retention  of  the  dis- 
charge beneath  the  prepuce.  The  latter  becomes  swollen,  and  there 
is  a  thick,  tender,  reddened,  cord-like  line  extending  along  the  dorsum 
of  the  penis. 

Bubo.  But  one  gland  is  commonly  affected,  this  may  undergo 
spontaneous  resolution  or  may  suppurate. 

Cowperitis.     Characterized  by   intense   throbbing    pain,  painful 


GONORRHCEA.  127 

urination,  especially  at  the  end  of  the  act,  owing  to  the  contraction 
of  the  compressor  urethrae  muscle,  and  the  detection  of  the  hard 
inflamed  glands  by  examination  along  the  perineum  or  through  the 
rectum.     The  second  stage  lasts  one  or  two  weeks. 

Give  the  symptoms  and  complications  of  the  stage  of  sub- 
sidence. 

The  symptoms  are  the  same  as  those  of  the  preceding  stages, 
excepting  that  they  steadily  grow  less  in  severity.  The  complica- 
tions which  may  develop  at  this  period  are  prostatitis  and  epididy- 
mitis. 

Prostatitis  is  characterized  by  pain  at  the  neck  of  the  bladder, 
increased  by  defecation  and  micturition.  The  pain  becomes  \Q\y 
intense,  and  the  perineum  feels  full,  hot  and  throbbing.  On 
examination  per  rectum  the  diagnosis  is  made  positive  by  the 
detection  of  a  hot,  tender,  enlarged  prostate.  This  inflammation 
is  commonly  accompanied  by  the  characteristic  constitutional  symp- 
toms of  acute  inflammation.  It  may  terminate  in  resolution,  in 
abscess,  or  in  chronic  inflammation. 

It  may  take  the  form  of  simple  congestion^  denoted  by  the  symp- 
toms detailed  above,  together  with  enlargement  and  tenderness  found 
on  rectal  examination.  This  is  the  most  frequent  form  of  inflam- 
mation which  attacks  the  prostate  in  the  course  of  acute  posterior 
urethritis.     It  usually  subsides  in  a  few  days. 

Or  the  inflammation  may  appear  as  an  acute  folliculitis,  due  to 
some  cause  exciting  a  renewed  intensity  of  posterior  urethritis,  such 
as  excessive  drinking  or  coitus.  The  symptoms  are  the  same  as 
before  ;  the  patient  complains  of  shooting  pains  during  the  passage 
of  the  last  drops,  there  is  a  burning  pain  during  urination  located 
in  the  deep  urethra,  and  rectal  examination  shows  the  prostate 
not  materially  enlarged,  but  presenting  one  or  two  sharply  defined 
nodules,  usually  in  one  lobe  only  ;  these  are  indurated,  markedly 
contrasting  with  the  soft  condition  of  the  remainder  of  the  gland. 
The  nodules  are  painful  on  pressure. 

Parenchjmatous  prostatitis,  m  addition  to  the  symptoms  accom- 
panying the  other  forms,  produces  marked  constitutional  reaction. 
The  local  sjTuptoms,  too,  are  exceedingly  severe,  and  rectal  tenesmus 
may  accompany  the  spasm  of  the  bladder.     Examination  shows  the 


128  ESSENTIALS  OF  SURGICAL  DRESSING. 

prostate  very  greatly  enlarged,  this  tumefaction  sometimes  being 
sufficient  to  cause  retention  of  both  urine  and  faeces.  At  the  end  of 
fi'om  five  to  seven  days  the  inflammation  may  undergo  spontaneous 
resolution,  or  suppuration  may  occui'. 

In  the  latter  case  the  pain  becomes  aggravated  and  throbbing,  and 
the  patient  complains  of  rigors  or  chills ;  pus  formation  is  exceed- 
iiigly  rapid.  At  times  these  prostatic  abscesses  develop,  although 
the  patient  complains  of  very  slight  symptoms. 

Epididymitis  is  characterized  by  pain  of  an  intense  and  sickening 
character,  radiating  fi'om  the  epididymis  along  the  cord  and  the  loins. 
The  epididymis  is  swollen  and  tender ;  there  is  commonlj'  marked 
fever.  Epididymitis  is  very  frequently  accompanied  by  effusion  into 
the  tunica  vaginalis.  In  this  case  the  swelling  may  be  diffused 
rather  than  localized  at  the  back  of  the  testis. 

Describe  subacute  or  catarrhal  gonorrhoea. 

This  form  of  gonorrhoea  usually  occurs  in  persons  who  have  had 
previous  attacks.  It  is  characterized  by  very  free  discharge,  with 
absence  of  other  symptoms  or  complications.  It  yields  readily  to 
treatment,  but  does  not  entkely  disappear,  a  drop  or  two  of  muco- 
pus  being  discharged  daily. 

What  are  the  complications  of  subacute  gonorrhcsa  ? 

Gonorrhoeal  rheumatism  or  urethral  synovitis.  This  is  character- 
ized by  comparatively  slight  constitutional  symptoms  at  first,  and  by 
rapid  development  of  synovitis,  affecting  by  preference  the  knee,  the 
ankle,  the  wrist,  the  finger  or  the  elbow. 

Gonorrhoeal  endocarditis,  gonorrhoeal  ophthalmia. 

Describe  irritative  or  abortive  gonorrhoea. 

The  symptoms  are  those  of  beginning  acute  gonorrhoea  ;  that  is, 
there  is  redness,  itching  and  tingling  of  the  meatus,  with  a  slight 
discharge.  The  disease,  however,  does  not  advance  beyond  this 
point.  These  symptoms  may  persist  for  several  days  and  then  dis- 
appear ;  there  may  be  no  complications  nor  sequelae. 

How  is  acute  gonorrhoea  diagnosed? 

By  the  presence  of  the  gonococcus.  These  microorganisms  are 
usually  abundant  and  readily  found  ;  this  is  so  universally  true  that 
failure  to  discover  them  on  carefal  examination  justifies  the  eonclu- 


GONORRHCEA.  129 

sion  that  an  acute  case  of  urethritis  is  not  really  gonorrhoeal  in 
nature. 

What  are  the  characteristics  of  the  gonococci? 

Under  a  high  magnifying  power  they  resemble  coffee  beans, 
their  concave  sides  being  directed  toward  each  other.  They  are 
found  in  groui^s  or  colonies  associated  in  twos  ;  they  do  not  appear 
in  chains  ;  colonies  of  the  gonococci  are  nearly  always  found  within 
pus  and  epithelial  cells. 

The  staining  of  the  gonococci  is  characteristic;  the  most  con- 
venient way  of  effecting  this  is  to  place  a  fraction  of  a  drop  of  the 
gonon'hoeal  discharge  upon  a  cover-glass,  place  over  this  another 
glass,  and  by  pressing  the  two  together  diffuse  the  matter  over 
the  surface  ;  place  the  cover  glass  in  the  air  to  dry,  then  pass 
it  three  times,  slowly,  through  the  flame  of  an  alcohol  lamp.  This 
cover-glass  preparation  is  then  dropped  pus  side  downward  upon  a 
solution  made  by  coloring  distilled  water  with  a  few  drops  of  an 
alcoholic  solution  of  fuchsin.  Subsequent  decolorization  by  Gram's 
method  makes  the  diagnosis  still  more  sure,  since  the  gonococcus 
readily  gives  up  its  stain,  thus  differing  from  other  microorganisms. 

How  is  acute  anterior  urethritis  distinguished  from  that 
attacking  the  posterior  urethra  ? 

By  an  examination  of  the  morning  urine.  If  the  disease  invades 
the  anterior  urethra  alone,  the  discharge  which  is  accumulated 
during  the  night  will  be  washed  away  by  the  first  portion  of  urine 
passed  on  rising,  and  the  last  portion  will  be  clear.  If  the  discharge 
takes  place  from  the  membranous  or  prostatic  portion  of  the  ui'ethra 
it  will  flow  backward,  and  will  be  diffused  in  the  urine  contained  in 
the  bladder  ;  hence,  though  the  first  portion  of  the  urine  may  con- 
tain an  excess  of  pus  and  mucus  washed  from  the  anterior  urethra, 
the  last  portion  will  also  be  found  to  contain  the  characteristic 
gonorrhoeal  discharge. 

What  elements  in  the  urine  denote  the  continuance  of  urethral 

inflammation  ? 
Pus,  mucus  and  clap-shreds.     Clap-shreds  consist  of  small  fila- 
ments, which  can  be  seen  floating  in  the  urine  by  the  naked  eye. 
On  microscopic  examination  they  are  found  to  be  composed  of  pus 

9 


130  ESSENTIALS   OF  SURGICAL  DRESSING. 

cells  entangled  in  mucin,    the  mucous  discharge   of  the   urethra 
having  been  coagulated  by  contact  with  the  acid  urine. 

What  is  the  prognosis  of  acute  gonorrhoea  ? 

The  prognosis  must  always  be  guarded,  particularly  in  the  case  of 
strumous,  feeble,  or  cachectic  individuals.  Though  this  disease  com- 
monly runs  an  uncomplicated  course  and  ends  shortly  in  complete 
cure,  it  may  continue  for  months  or  years. 

A  first  infection  usually  runs  a  more  rapid  course  than  subsequent 
attacks. 

When  the  disease  remains  limited  to  the  anterior  urethra  the 
chances  for  rapid  recovery  are  much  more  favorable  than  when  it  has 
extended  to  the  posterior  urethra. 

What  is  the  treatment  for  acute  anterior  urethritis  ? 

Prophylactic. — Prolonged  and  repeated  coitus  has  a  marked  in- 
fluence in  encouraging  the  entrance  of  the  gonococcus  into  the 
urethra.  Hence  a  brief  contact  is  desirable  from  a  prophylactic 
standpoint.  Immediate  urination  after  coitus  and  thorough  washing 
of  the  penis  should  also  be  practised.  The  wearing  of  a  clean  strong 
rubber  pouch  is  the  most  effective  way  of  guarding  against  contagion. 

Curative. — As  much  bodily  and  mental  rest  as  possible  should  be 
recommended  ;  rest  in  bed  is  a  most  efficient  means  of  shortening 
the  disease,  or  at  least  of  insuring  a  mild  course.  This,  however,  is 
rarely  possible,  since  the  necessity  for  secrecy  forces  the  patient  to 
continue  his  daily  routine  of  life.  Violent  physical  exertion  should 
he  positively  interdicted.  Diet  should  be  light,  with  a  minimum 
amount  of  meat,  and  total  avoidance  of  puddings,  pies,  highly 
seasoned  foods  or  indigestible  articles.  An  exclusively  liquid  diet, 
together  with  large  quantities  of  alkaline  waters,  is  not  to  be  x^gqur- 
mended,  since  this  frequently  disorders  the  stomach. 

A  suspensory  bandage  arranged  to  support  and  elevate  the  ex- 
ternal genitalia  should  be  worn  from  the  first.  Sexual  excitement, 
even  that  resulting  from  meretricious  reading  matter,  must  be  strictly 
avoided.  The  patient  should  sleep  on  a  hard  bed  with  the  lightest 
covering  compatible  with  comfort.     The  bowels  must  be  kept  open. 

If  the  ardor  urince  becomes  so  marked  as  to  cause  serious  dis- 
comfort a  prescription  such  as  the  following  should  be  given  : — 


GONORRHCEA.  131 

R.     Potass,  bicarb., f^vj 

Tr.  hyoscy., f.^iv 

Muciiag.  ulm., f^XJ,     M. 

SiG. — Tablespoonful  in  a  glass  of  Vichy  water  every  3  hours. 

Great  relief  will  be  obtained  by  immersing  the  penis  in  hot  water 
during  urination,  or  by  the  application  of  a  4  to  10  percent,  solution 
of  cocaine  to  the  meatus  just  before  the  water  is  passed.  This  may 
be  conveniently  accomplished  by  wrapping  the  end  of  a  match  in  a 
small  piece  of  absorbent  cotton,  dipping  the  latter  in  a  cocaine  solu- 
tion and  passing  it  within  the  urethra  to  the  depth  of  one  inch.  In 
three  minutes  the  effect  of  the  drug  will  be  produced. 

If  the  penis  swells  and  becomes  cedematous  it  may  be  wrapped  in 
cloths  saturated  in  the  following  solution  : — 

R  .     Ext.  hamamel.  fl., 

Alcohol. , 

Aquae, aa •  f^iv.     M. 

SiG. — Locally. 

Painful  erections  are  best  combated  by  camphor,  lupulin,  and  bro- 
mide of  potassium  administered  by  the  mouth,  though  care  must 
be  taken  that  the  stomach  is  not  disordered  thereby.  To  be  efficient 
these  drugs  must  be  administered  in  full  doses  ;  from  thirty  to  sixty 
grains  of  bromide  may  be  taken  at  bedtime,  and  the  dose  may  be 
repeated  during  the  night  if  the  symptoms  require  it.  Lupulin  should 
be  given  in  from  five-  to  ten-grain  doses. 

Probablj^  the  best  means  of  controlling  painful  erections  is  the  ad- 
ministration hyi)odermically  of  a  quarter  of  a  grain  of  morphia 
together  with  a  sixth  of  a  grain  of  atropia,  into  the  perineum, 
either  on  retiring  or  during  the  night.  The  patient  should  be 
instructed  to  rise  once  or  twice  and  micturate.  Suppositories  may 
also  be  employed.  Of  these  perhaps  the  best  is  one  containing 
extract  of  hyoscyamus,  gr.  ^  ;  extract  of  opium,  gr.  j. 

When  the  discharge  is  free  it  will  be  necessary  to  devise  some 
plan  by  which  it  may  be  prevented  from  soiling  the  clothing.  This 
may  be  accomplished  by -retracting  the  prepuce,  covering  the  glans 
penis  with  absorbent  cotton  and  drawing  the  foreskin  forward  ;  or 
by  cutting,  in  a  small,  square  piece  of  muslin  rag,  a  slit  sufficiently 
large  to  admit  the  head  of  the  penis  ;  this  opening  is  carried  back 
until  it  is  behind  the  corona,  a  wad  of  cotton  is  then  applied  to  the 


132  ESSENTIALS   OE   SURGICAL  DRESSING. 

meatus  and  the  foreskin  is  drawn  forward.  This  dressing  separates 
the  mucous  surfaces  of  the  glans  and  prepuce  and  prevents  the 
development  of  balanitis,  while,  at  the  same  time,  it  allows  of  the 
retention  of  a  comparativelj^  large  wad  of  cotton.  Where  the  dis- 
charge is  very  free  and  this  is  not  sufficient,  or  where  the  conforma- 
tion of  the  organ  is  such  that  this  dressing  cannot  be  retained,  the 
patient  may  be  instructed  to  pin  a  small  muslin  bag  or  the  foot  of  a 
stocking  to  his  shirt ;  in  the  bottom  of  this  bag  is  placed  a  sufficient 
quantity  of  cotton,  which  receives  the  discharge,  the  penis  being  so 
dressed  that  it  hangs  in  the  bag. 

During  the  increasing  stage  of  gonorrhoea,  local  or  systemic 
remedies  must  be  used  with  extreme  caution,  since  there  is  great 
danger  of  increasing  inflammation,  and  thereby  favoring  the  growth 
and  the  extension  of  the  gonococci.  From  the  beginning  of  the 
attack  the  following  remedies  may  be*  administered  by  the  mouth, 
with  the  idea  of  rendering  the  urine  aseptic  and  thus  inhibiting  the 
growth  of  the  germs  : — 

R .     Salol, gr.  X 

Balsam  of  copaiba, TTLj. 

Encapsulat. 
SiG. — Take  one  such  capsule  four  times  a  day. 

Injections  or  local  applications  should  rarely  be  used  until  the 
height  of  the  inflammatory  stage  is  past.  This  will  be  in  from  seven 
to  fourteen  days.  Then  the  following  injection  will  be  found  use- 
ful :— 

R .     Sulphocarbolate  of  zinc,      gr.  v 

Bichloride  of  mercury,  .  .  .  .  ,  -  gr.  ij 
Hydrogen  peroxide  (Marchand),  .  .  f^iss 
AYater, q.  s., f^viij. 

This  injection  must  be  given  in  such  a  strength  that  it  does  not 
cause  severe  pain  or  excite  marked  inflammatory  reaction. 

The  general  principles  covering  all  injections  are  that  the  urethra 
should  be  cleansed  by  urination  immediately  before  the  introduction 
of  the  injection,  that  the  latter  should  be  introduced  gently  and  with 
uniform  pressure,  and  that  a  sufficient  quantity  should  be  introduced 
to  distend  the  entire  anterior  urethra.  The  best  syringe  for  this 
purpose  is  one  provided  with  a  conical  point,  which  fits  the  meatus 


GONORRH(EA.  133 

ratlier  tlian  enters  tlie  uretlira,  and  wliicli  has  a  piston-rod  wliich 
slips  easily  and  without  any  irregular  or  jerking  motion.  A  soft 
rubber  bulb  provided  with  a  conical  point,  answers  the  requirements 
of  an  injection  apparatus  better  than  any  of  the  instmments  pro- 
vided with  a  piston-rod.  The  injection  should  be  made  at  first 
twice  a  day,  the  patient  being  instructed  to  add  water  to  the  solu- 
tion employed  until  it  is  no  longer  acutely  painful.  As  the  dis- 
ease becomes  more  chronic  in  type  the  injections  may  be  employed 
more  frequently,  five  or  six  a  day  being  administered.  In  place  of 
the  solution  given  above,  any  of  its  ingredients  may  be  given  indi- 
vidually, rose  water  being  used  as  an  excipient. 

A  very  successful  means  of  treatment   and  one  which  may  be 

Fig.  66. 


Tube  for  Irrigating  the  Anterior  Urethra. 

employed  in  the  very  beginning  of  the  disease,  consists  in  copious 
injections  of  hot  bichloride  of  mercury  solutions  1-40,000  or  per- 
manganate of  potassium  solution  1-40,000  to  1-15,000.  Two  to 
four  pints  of  this  lotion  are  injected  twice  a  day,  by  means  of  either 
a  nozzle  fitting  into  the  meatus  and  pro^dded  with  an  entrance  and 
exit  pipe,  or  a  catheter  provided  with  a  bulb  at  its  extremity  and 
with  the  openings  pointed  backward.  If  the  latter  is  used  it  is 
introduced  down  to  the  membranous  portion  of  the  urethra  ;  to  its 
extremity  is  attached  the  pipe  coming  from  the  irrigating  apparatus, 
and  the  bichloride  lotion  is  allowed  to  flow  from  behind  forward. 
Starting  with  a  temperature  of  about  105°,  the  solution  is  gradually 
made  as  hot  as  the  patient  can  endure.  When  it  does  not  produce 
a  cure,  it  at  least  lessens  the  severity  of  the  sj'mptoms  during  the 
increasing  and  stationary  stages. 
The  abortive  plan  of  treatment  has  been  revived  in  recent  times. 


134 


ESSENTIALS  OF   SURGICAL  DRESSING. 


Fin 


For  this  purpose  solutions  of  nitrate  of  silver,  varj'ing  in  strength 
from  eight  to  sixteen  grains  to  the  ounce,  may 
be  emplo,yed.  After  urination,  a  syringeful  of 
this  solution  is  injected  into  the  urethra.  This 
is  retained  for  one  or  two  minutes,  it  is  then 
allowed  to  escape  and  a  one  per  cent,  solution 
of  sodium  chloride  is  injected,  to  neutralize  any 
excess  of  nitrate  of  silver  which  may  remain. 

These  injections  may  be  repeated  every  third 
day,  and  are  said  to  be  frequently  followed  by 
a  cure  of  disease  in  from  seven  to  twelve  days. 
The  inflammation  following  these  injections  is 
combated  by  entire  rest,  the  application  of 
heat  or  cold,  evaporating  lotions,  etc.  The 
pain  attendant  upon  them  may  be  greatly 
diminished  by  the  previous  injection  of  a  four 
l^er  cent,  solution  of  cocaine. 

It  must  be  borne  in  mind  that,  even  though 
the  discharge  has  ceased  entirely,  it  is  not  safe 
to  suddenly  discontinue  the  injections.  These 
should  be  continued  for  at  least  twelve  days 
after  the  subsidence  of  all  symptoms,  and 
should  then  be  dropped  very  gradually.  Dur- 
ing the  subsiding  stage  of  the  disease,  if  the 
discharge  seems  to  resist  the  injections  advised 
above,  the  use  of  soluble  urethral  bougies  is 
frequently  attended  by  veiy  satisfactory  results. 
A  bougie  containing  sulphate  of  zinc  half  a 
grain,  oxide  of  zinc  two  grains,  and  hydrastis 
canadensis  five  grains,  may  be  introduced  on 
retiring,  and  may  be  secured  in  place  by  a 
small  pledget  of  cotton  strapped  over  the 
meatus  by  adhesive  plaster. 

^^StS?""  How  do  you  determine  as  to  whether  or  not 

acute  anterior  urethritis  is  cured? 
By  an  examination  of  the  morning  urine.     If  this  contains  no 
pus,  no  mucus,  and  no  clap-shreds,  the  disease  can  be  regarded  as 


GONORRHCEA.  135 

definitely  cured.  If.  however,  pus  and  clap-shreds  are  found,  even 
though  the  patient  declare  positively  that  he  is  entirely  free  from 
symptoms,  treatment  must  not  be  mtermitted. 

Frequently  there  will  remain  for  months  after  a  gonorrhoea  is 
definitely  cured  a  slight  discharge  of  mucus.  This  perhaps  is  a 
clear  drop,  particularly  noticeable  in  the  morning,  and  annoying  the 
patient  by  gluing  the  lips  of  the  meatus  together.  For  this  condition 
local  treatment  is  usually  worse  than  useless.  Strong  astringent 
medication  will  cause  irritation  and  subacute  inflammation  of  the 
urethral  mucous  membrane,  and  will  probably  cause  the  discharge 
to  become  purulent.  The  hyper-secretion  of  mucus  will  gradually 
diminish,  however,  under  general  hygienic  and  constitutional  treat- 
ment. If  microscopic  examination  shows  absence  of  pus  the  surgeon 
should  not  be  induced  to  consent  to  local  treatment,  even  though 
this  discharge  persist  for  weeks  or  months. 

What  is  the  treatment  of  acute  posterior  urethritis  ? 

As  in  the  case  of  anterior  urethritis,  during  the  continuance  of 
hyper-acute  inflammation  all  local  treatment  must  be  avoided ; 
even  topical  applications  to  the  anterior  urethra  must  be  stopped  the 
moment  frequent  and  painful  micturition  together  with  other  symp- 
toms of  the  extension  of  the  disease  into  the  posterior  urethra 
appear.  The  symptom  demanding  most  attention  is  usually  violent 
tenesmus,  often  accompanied  by  bleeding.  The  patient  is  tortured 
by  a  constant  desire  to  urinate,  a  desire  entirely  unrelieved  by  passing 
the  few  drops  which  remain  in  the  bladder,  and  at  the  end  of  the  act 
he  may  have  a  free  flow  of  blood.  Here  the  general  antiphlogistic 
treatment  of  urethritis  is  applicable.  The  urine  must  be  made 
bland  by  moderate  dilution  by  means  of  slightly  alkaline  efiervescing 
waters,  partial  milk  diet,  or  the  free  administration  of  bicarbonate 
of  soda  or  citric  acid.  The  bowels  must  be  kept  soluble,  and 
bromides  and  other  sedatives  may  be  administered  by  the  mouth. 
The  most  prompt  relief  will  follow  hypodermics  of  morphia  and 
atropia  introduced  into  the  perineum,  or  the  employment  of  opium 
and  belladonna  suppositories. 

Prolonged  warm  baths  are  also  of  great  service,  and  should  be 
taken  night  and  morning.  At  times  reflex  spasm  is  so  great  that 
dysuria  develops.     The  catheter  should  be  used  only  as  a  last  resort, 


136  ESSENTIALS   OF  SURGICAL  DRESSING. 

and  the  softest  instruments  that  can  be  introduced  should  be 
employed.  Even  duiiug  the  height  of  inflammation  the  capsules 
advised  before  may  be  administered,  unless  they  seem  to  aggravate 
the  local  condition  ;  if  this  is  the  case  they  must  at  once  be  discon- 
tinued. If  the  acute  symptoms  have  disappeared,  after  three  or 
four  days  local  treatment  may  be  instituted.  Applications,  to  be  of 
service,  must,  of  course,  be  brought  in  contact  with  the  inflamed 
mucous  membrane ;  this  can  be  accomphshed  only  by  means  of 
instraments  canied  into  the  posterior  urethra.  A  soft  nibber 
catneter,  together  with  an  ordinary  surgical  .syringe,  the  nozzle  of 
which  fits  into  the  extremity  of  a  catheter,  will  answer  well  for  this 
local  treatment.  The  catheter  should  be  introduced  until  urine 
begins  to  flow,  when  it  is  withdrawn  until  the  flow  ceases.  The 
nozzle  of  the  syringe  is  then  inserted  into  the  end  of  the  catheter, 
and  from  an  ounce  to  an  ounce  and  a  half  of  the  following  prescrip- 
tion injected,  the  catheter  being  slowly  withdrawn  during  the  course 
of  the  injection.  Since  p)Osterior  urethritis  is  always  accompanied 
by  inflammation  of  the  anterior  urethra,  it  is  perfectly  proper  to 
apply  the  injection  to  the  whole  mucous  canal. 


Or— 


Carbolic  acid, 2  grains, 

Distilled  water,    .,.,..,..  2  ounces. 

Nitrate  of  silver,  .    .    .    .   .    .    ,    .    .  J  to  2  grains, 

Distilled  water 2  ounces. 


Not  more  than  two  ounces  of  either  of  these  solutions  should  be 
injected  at  one  time,  and  the  injection  should  not  be  repeated  more 
frequently  than  once  every  second  day.  The  nitrate  of  silver  injec- 
tions are  particularly  valuable,  and  the  strength  of  the  solution 
should  be  gradually  increased  as  the  mucous  membrane  becomes 
more  tolerant  of  the  action  of  the  drag. 

The  inflammation  of  the  posterior  urethra  is  usually  cui'ed  before 
that  of  the  anterior  portion  of  the  tube.  When  examination  shows 
that  the  second  urine  is  clear,  while  the  first  contains  pus  and 
mucus,  posterior  applications  may  be  discontinued.  The  treatment 
of  anterior  urethritis  may  then  be  kept  up  by  the  ordinary  clap 
sjTinge,  as  advised  above. 


GONORRHCEA.  137 

How  are  the  complications  of  acute  urethritis  treated  ? 

Balanitis  and  Posthitis  are  treated  by  retracting  the  preiDuce  and 
bathing  the  penis  in  dilute  carbohc  lotion,  2  per  cent.,  or  weak  bichlo- 
ride solution.  The  parts  are  then  carefully  dried  with  absorbent  cot- 
ton, dusted  with  a  little  bismuth  powder  or  oxide  of  zinc,  and  a  layer 
of  absorbent  cotton  is  laid  over  the  glans  penis  so  that  the  mucous 
surfaces  do  not  come  in  contact  when  the  foreskin  is  drawn  forward. 
Where  there  are  superficial  ulcerations  these  may  be  quickly  healed 
by  brashing  with  a  4  per  cent,  solution  of  nitrate  of  silver,  or  by 
touching  with  the  solid  stick.  If  the  discharge  is  very  profuse 
powdered  tannin  acts  well  as  a  dusting  powder. 

Phimosis  requires  careful  cleansing  ;  the  whole  prepuce  should  be 
douched  out  by  means  of  an  ordinary  injection  syringe,  and  this 
process  should  be  repeated  many  times  until  all  the  discharge  is 
cleared  away.  A  solution  of  nitrate  of  silver,  four  grains  to  the 
ounce,  is  then  injected,  and  the  penis  is  wrapped  in  cloths  wet 
with  lead  water  and  laudanum.  The  pus  should  be  evacuated  by 
means  of  these  washings  at  least  six  times  during  the  day,  and  the 
nitrate  of  silver  solution  should  be  employed  morning  and  night. 
Very  marked  oedema  may  require  scarification.  At  times  splitting 
up  of  the  foreskin  or  circumcision  may  be  necessary. 

Paraphimosis  should,  if  possible,  be  reduced  as  soon  as  discovered  ; 
this  may  sometimes  be  effected  by  manipulation,  or  if  this  fails  the 
glans  may  be  covered  with  lint  and  enveloped  from  before  back- 
ward in  an  elastic  band.  A  director  is  then  slipped  beneath  the 
constricting  ring,  the  elastic  wrappings  are  removed  and  an  effort 
made  to  draw  the  prepuce  forward.  If  this  fails  the  paraphimosis 
must  be  reduced  by  making  an  incision. 

Follicular  and  periurethral  abscesses  are  in  the  first  place  treated 
according  to  the  principles  governing  the  therapeutics  of  all  acute  in- 
flammations ;  both  the  local  and  general  treatment  of  gonorrhoea  must 
at  once  be  discontinued.  Cold  compresses,  or  hot  fomentations,  or  the 
hot-water  bag  may  be  employed.  If  fluctuation  is  detected  an  ex- 
ternal opening  should  be  made.  Where  urinary  infiltration  is  threat- 
ened, or  has  already  occurred,  the  treatment  consists  in  free  incision, 
and  the  insertion  of  a  soft  catheter  into  the  bladder,  the  latter  being 
allowed  to  remain.  Should  the  inflammation  undergo  partial  resolu- 
tion, but  leave  an  indurated  nodule,  local  inunctions  of  mercury 


138  ESSENTIALS   OF  SURGICAL  DRESSING. 

ointment  maj^  be  advised.  "Where  this  induration  is  at  all  ex- 
tensive erections  must  be  carefully  guarded  against  until  absorption 
has  taken  place,  as  otherwise  nipture  and  serious  hemorrhage  may 
follow. 

Inflammation  of  the  follicles  of  the  meatus  are  treated  by  thmst- 
ing  the  sharp  point  of  a  stick  of  nitrate  of  silver  into  the  glands. 

Coivperitis.  In  addition  to  the  general  treatment  suitable  to 
inflammations  this  complication  may  be  combated  by  ice  bags  to  the 
perineum.  Cowperitis  is  subject  to  the  same  treatment  as  periure- 
thral abscesses. 

Prostatitis  demands  prompt  suspension  of  local  treatment  directed 
against  the  gonorrhoea.  The  bowels  must  be  kept  soluble  and 
the  urine  should  be  rendered  bland  and  antiseptic.  Troublesome 
sjmiptoms  are  combated  by  perineal  hypodermics  of  morphia  and 
atropia.  Rest  in  bed,  counter-irritation  applied  to  the  perineum, 
preferably  by  means  of  small,  repeated  blisters,  and  copious  injections 
of  very  hot  water,  are  usually  successful  in  preventing  suppuration. 
A  fountain  syringe  is  j^rovided,  large  enough  to  hold  two  quarts  of  fluid, 
a  supply  pipe  from  this  is  attached  to  a  two-way  rectal  tube,  and  the 
latter  is  introduced  into  the  anus  so  that  the  stream  flowing  from 
the  irrigator  impinges  directly  upon  the  inflamed  and  enlarged  pros- 
tate. Starting  at  about  105°  the  temperature  of  the  injection  fluid  is 
gradually  raised  until  it  is  made  as  hot  as  the  patient  can  endure. 
Two  quarts  of  water  are  thus  injected  twice  a  day,  and  a  hot  water 
bag  is  worn  against  the  perineum  during  the  intervals  of  treatment. 

At  times  injections  of  cold  water  seem  to  produce  a  more  prompt 
effect.  The  choice  will  depend  to  a  great  extent  upon  the  feelings 
of  the  patient.  When  suppuration  takes  place  the  abscess  cavity 
must  be  incised  through  the  perineum  and  treated  in  accordance 
with  ordinary  surgical  principles 

Should  retention  of  the  urine  occur,  not  relieved  by  prolonged  hot 
baths  and  opium  and  belladonna  suppositories,  a  soft  catheter  may 
be  passed. 

What  is  the  treatment  of  epididymitis  ? 

The  treatment  of  acute  epididymitis  is  conducted  on  the  same 
general  lines  as  in  the  case  of  any  local  inflammation.  Rest,  eleva- 
tion, counter-irritation,  etc.,  are  all  indicated. 


GONORRHCEA. 


139 


The  dressing  which  is  most  satisfactory  in  the  treatment  of  this 
affection  is  appHed  as  follows  : — 

The  testicles  are  enveloped  in  a  thick  layer  of  cotton  ;  outside  of 
this,  and  of  sufficient  size  to  envelope  the  entire  scrotum,  is  placed 
a  piece  of  rubber  or  other  impervious  material.  The  dressing  is  then 
completed  by  a  suspensory  bandage  gored  at  the  sides  and  provided 
with  lacings,  so  that  it  may  be  tightened  to  accurately  fit  the  testicles. 
By  means  of  this  dressing  the  patient  may  pursue  his  ordinary  avoca- 
tions without  inconvenience  to  himself  and  without  materially  com- 
plicating or  lengthening  the  course  of  his  disease.  This  dressing 
accomplishes  the  good  derived  from  pressure,  heat  and  moisture — 

Fig.  68. 


Suspensory  Bandage  for  Epididymitis. 


all  powerful  means  of  combating  acute  inflammations.  It  may  be 
used  from  the  beginning,  and  is  frequently  followed  by  relief  of  pain 
within  half  an  hour  of  its  application. 

Since  epididymitis  is  frequently  complicated  by  effusion  into  the 
tunica  vaginalis,  the  latter  may  be  punctured,  and  the  evacuation  of 
serum  thus  accomplished  often  markedly  alleviates  the  suffering  of 
the  patient.  The  knife  should  not  be  carried  into  the  substance  of 
the  epididymis  or  through  the  tunica  albuginea  testis.  After  all 
symptoms  of  acute  inflammation  have  passed  there  is  frequently  left 
an  indurated  spot  about  the  tail  of  the  epididymis.  Every  effort 
should  be  made  to  cause  the  absorption  of  this  induration,  since,  if 
it  remains,  it  may  entirely  cut  off  the  secretion  of  the  testicle,  and. 


140  ESSENTIALS   OF  SURGICAL  DRESSING. 

where  the  disease  is  bilateral,  may  result  in  sterility  ;  hence  contin- 
uance of  the  dressing  described  above,  combined  with  local  applica- 
tions of  mercury  and  belladonna  ointment,  is  desirable. 

Chronic  Gonorrh(ea. 

What  are  the  causes  of  chronic  urethral  discharge  ? 

(1)  Uretliral  catarrh . 

(2)  Chronic  gonorrhcea^  and  localization  of  the  disease,  producing 
granular  surfaces. 

Stricture  of  the  Urethra.     This  is  the  usual  cause  of  gleet. 

How  can  the  nature  of  chronic  urethral  discharge  be  deter- 
mined ? 

Urethral  catarrh  immediately  follows  gonorrhoea,  and  presents  no 
symptoms  beyond  a  thin  watery  discharge.  Microscopic  examination 
of  this  discharge  shows  that  it  is  composed  of  mucus,  mucous  corpus- 
cles and  epithelium.     Pus  corpuscles  are  absent. 

Chronic  gonorrhoea  is  characterized  by  a  more  or  less  profuse 
discharge  of  creamy  pus.  It  is  greatly  aggravated  by  any  excess, 
and  exacerbations  occur,  the  cause  of  which  cannot  be  definitely 
determined.  During  the  exacerbation  there  is  frequently  burning 
during  urination,  and  at  times  chordee.  It  is  usually  located  either 
in  the  bulbous  or  membranous  portion  of  the  urethra,  or  about  the 
navicular  fossa.  Examination  by  the  bulbous  bougie  detects  a  tender 
spot,  and  pus  and  blood  may  be  brought  away  on  the  shoulder  of  the 
instrument. 

Gleet  and  stricture  often  appear  some  time  after  the  apparent  cure 
of  an  attack  of  gonorrhoea.  This  is  characterized  by  a  muco-purulent 
discharge,  and,  if  the  stricture  becomes  contracted  by  frequent  urina- 
tion with  an  imperfect  cut  off.  On  passing  a  bulbous  bougie  narrow- 
ing is  detected. 

How  can  the  seat  of  chronic  urethral  disease  be  determined  ? 

It  is  of  the  greatest  importance  to  distinguish  between  chronic 
urethritis  located  in  the  anterior  urethra  and  that  which  has  its  seat 
in  the  posterior  portion  of  the  canal.  This  can  readily  be  determined 
by  an  examination  of  the  urine.  If  the  first  portion  of  the  urine 
passed  on  rising  contains  pus,  while  the  second  is  clear,  the  seat  of 


GONORRHCEA. 


141 


Fig.  69. 


the  discliarge  is  necessarily  located  anterior  to  the  compressor 
urethra3  muscles.  If,  however,  the  last  urine  con- 
tains the  discharge  of  chronic  gonorrhoea  this  shows 
that  tlie  posterior  urethra  is  invaded.  The  accurate 
localization  of.  the  process  maybe  further  determ- 
ined by  the  passage  of  bulbous  bougies,  and  by  the 
use  of  the  urethroscope.  If  there  is  erosion  of  any 
part  of  the  urethra,  as  the  bougie  slips  over  this 
portion  the  patient  will  complain  of  pain.  One 
examination  is  not  sufficient  on  this  point ;  it  is 
only  when,  after  the  repeated  passage  of  instru- 
ments, pain  is  referred  to  one  particular  spot,  that 
the  surgeon  can  be  sure  that  here  is  located  a  focus 
of  disease. 

If  the  discharge  is  persistent  in  spite  of  careful 
treatment  the  uretnroscope  should  always  be  used. 
A  straight  hard  rubber  tube,  provided  with  a 
rounded  obturator  which  projects  somewhat  bej^ond 
the  end  of  the  instrument,  represents  the  simplest 
form  of  this  instrument.  To  allow  of  a  satisfactory 
view  the  tube  should  be  of  as  large  calibre  as  can  be 
passed  into  the  urethra,  and  should  be  just  long- 
enough  to  reach  the  bladder  when  the  penis  is 
shortened  as  much  as  possible.  This  instrument  is 
introduced  until  the  bladder  is  reached,  the  urethro- 
scopic  tube  is  slightly  withdrawn,  and  the  surgeon 
reflects  from  a  head  mirror  as  strong  a  light  as 
possible  into  the  urethroscope.  As  the  tube  is 
withdrawn  the  various  portions  of  the  urethra  are 
exposed  to  view.  When  pus  and  blood  obstruct 
the  field  of  vision  they  can  be  removed  by  pledgets 
of  cotton  carried  in  by  long  applicators.  This  per- 
mits of  a  most  accurate  diagnosis.  The  Leiter 
incandescent  urethroscope  affords  a  much  better 
illumination,  but  the  cheaper  and  simpler  instru- 
ment will  be  found  to  give  satisfactory  results. 

The  extent  of  inflammation  can  further  be  deter- 


Crethroscope. 


mined  by  examination  of  the  urine.     If  the  latter  contains  only  clap- 


142  ESSENTIALS  OF  SURGICAL  DRESSING. 

shreds  the  i^robabilities  are  that  the  disease  is  locahzed ;  if,  how- 
ever, large  quantities  of  mucus  are  present  it  is  almost  certain  that 
an  extensive  area  of  mucous  membrane  is  involved  in  the  inflam- 
matory process. 

Give  the  treatment  of  chronic  urethral  discharge. 

Urethral  catarrh  is  denoted  by  profuse  mucous  discharge ;  if  not 
accompanied  by  foci  of  ulceration  or  by  narrowing  of  the  urethra,  it 
is  best  treated  constitutionally.  Open  air,  nourishing  diet,  tonics, 
iodide  of  iron,  in  fact  everything  which  tends  to  improve  the 
patient's  general  condition,  should  be  advised. 

If  any  local  treatment  is  adopted  it  should  be  of  the  mildest  char- 
acter. The  internal  administration  of  co])aiba,  cubebs  and  salol  may 
be  supplemented  by  very  weak  injections  of  a  .5  solution  of  sulphate 
of  zinc,  nitrate  of  silver,  or  sulphate  of  copper. 

When  in  addition  to  the  general  catarrhal  condition,  there  are 
likewise  areas  of  ulceration,  the  general  catarrhal  congestion  has 
first  to  be  subdued ;  this  is  best  combated  by  the  means  just 
described,  one  injection  being  given  twi«"e  daily.  If  the  posterior 
urethra  is  also  involved  in  the  catarrhal  process,  the  same  solutions 
may  be  used,  but  should  be  introduced  by  means  of  a  rubber 
catheter  passed  to  the  prostatic  portion  of  the  urethra ;  through 
this  the  injecting  fluid  is  slowly  forced  as  the  catheter  is  withdrawn 
from  the  urethra.  These  irrigations  should  be  repeated  eveiy 
second  or  third  day,  depending  upon  the  amount  of  reaction  they 
excite. 

When,  on  examination,  the  urine  is  found  to  contain  only  shreds 
or  flocculi,  the  mucous  secretion  having  disappeared,  it  may  be 
assumed  that  the  general  catarrhal  condition  is  allayed.  Treat- 
ment may  now  be  directed  to  the  ulcerated  foci.  If  the  seat  of  the 
disease  is  located  in  the  anterior  urethra  it  may  be  conveniently 
reached  by  '^^"'e  hard  rubber  endosco]3ic  tube.  The  astringent  solu- 
tions are  applied  by  means  of  cotton  wound  on  a  long  applicator ; 
four  per  cent,  solutions  of  either  nitrate  of  silver  or  sulphate  of 
copper  may  be  employed.  W^hen  used  in  this  strength  the  medica- 
tion should  be  brought  in  contact  onlj'  with  the  diseased  surface. 

When  the  disease  is  located  in  the  membranous  or  prostatic  por- 
tions of  the  urethra,  a  few  drops  of  either  copper  or  silver  solution, 


GONORRHCEA.  143 

varying  in  strength  fi'om  one  to  two  per  cent. ,  may  be  introduced  by 
means  of  Ultzmann's  prostatic  catheter ;  glycerin  should  be  employed 
as  a  lubricant  for  the  instrument,  since  oil  protects  the  mucous  mem- 
branes from  the  action  of  the  remedies.  A  verj^  excellent  method 
of  treating  inflammation  of  the  posterior  urethra  is  offered  in  the 

Fig.  70. 


Ultzmann's  Prostatic  Catheter. 

form  of  lanolin  ointment.  For  the  purpose  of  api^lying  this  a 
catheter  provided  with  a  piston  rod  must  be  filled  with  the  oint- 
ment ;  the  catheter  is  then  inserted  into  the  prostatic  portion  of  the 
urethra,  and  the  medication  is  forced  out  of  the  tube  by  means  of 
the  piston  rod.     The  ointment  preferred  by  Finger  is  as  follows  : — 

Nitrate  of  silver,  tannin,  or  sulphate 

of  copper, gr.  XV 

Lanolin, ^j 

Olive  oil, ,^iss. 

These  applications  may  be  repeated  every  second  or  third  day. 
A  very  successful  method  of  treating  chronic  gonon-hoea,  when  the 
lesions  consist  of  foci  of  ulceration  together  with  a  good  deal  of 
catarrh,  is  by  means  of  Unna's  medicated  sounds.  An  ointment  is 
prepared  as  follows  : — 

Nitrate  of  silver, gr.  xv 

Balsam  of  Peru, 3  ss 

Yellow  wax,      5  ss 

Coca  batter, '•    •  Siij- 

This  mass  is  liciuefied  by  heat,  the  sound  is  dipped  in  it  and  is 
then  hung  up  to  drj^  When  these  sounds  are  introduced  the 
heat  of  the  body  melts  the  coating,  and  thus  the  whole  urethra 
is  medicated  by  the  nitrate  of  silver. 


144  ESSENTIALS  OF  SURGICAL  DRESSING. 

The  soluble  medicated  bougies  also  offer  au  excellent  method  of 
applying  topical  applications  to  the  entire  urethra.  These  are  made 
in  long  and  short  sizes.  One  should  be  inserted  at  night  and  should 
be  kept  in  place  by  a  pledget  of  cotton  pressed  to  the  meatus  and 
held  there  by  a  rubber  adhesive  strap. 

The  bougies  containing  sulphate  of  zinc,  hydrastis  canadensis, 
carbolate  of  zinc  and  carbolic  acid,  are  most  valuable.  It  must  be 
borne  in  mind,  however,  that  these  applications  medicate  the  entire 
urethra  and  are  not  indicated  unless  the  local  ulceration  is  accom- 
panied by  widespread  catarrhal  processes. 

The  chronic  discharge  depends,  in  the  majority  of  cases,  upon 
the  presence  of  stricture  which,  in  turn,  is  often  accompanied  by 
ulceration  of  the  mucous  membrane  on  the  proximal  side.  These 
strictures  may  depend  upon  swelling  and  turgescence  of  the  mucous 
membrane  or  may  be  due  to  a  distinct  deposit  of  inflammatory 
tissue,  the  process  of  cicatrization  causing  narrowing  of  the  urethral 
canal. 

What  is  stricture  of  the  urethra  ? 

True  organic  stricture  is  a  permanent  narrowing  of  the  urethral 
canal  at  one  or  more  points,  due  to  disease,  injury,  or  congenital 
defect.     There  are  also  spasmodic  or  congestive  strictures. 

What  are  the  causes  of  strictures  ? 

Gonorrhoea,  traumatism,  ulceration  and  masturbation. 

What  are  the  varieties  of  urethral  stricture  ? 

In  regard  to  cause  we  have  an  idiopathic^  traumatic  and  inflam- 
matory. 

In  regard  to  anatomical  appearances  bridle  stricture.  A  band  of 
lymph  attached  only  by  its  ends,  stretching  across  the  urethra.  An- 
nular. A  circular  constriction  as  though  a  string  were  tied  about 
the  urethra.     Indurated  Annular.     Cartilaginous. 

In  regard  to  the  possibility  of  passing  instruments  strictures  are 
classed  as  permeable  and  impermeable. 

In  regard  to  their  behavior  on  manipulation,  they  may  be  simple, 
irritahJe,  contractile  or  recurring. 

What  are  the  favorite  seats  of  stricture  ? 
At  the  anterior  part  of  the  urethra,  and  just  in  front  of  the  mem- 


GONORRHCEA. 


im 


branous  portion.     Strictures  are  never  found  in  the  prostatic  portion 
of  the  urethra. 


What  are  the  consequences  of  an 
untreated  stricture  ? 
Hyperaemia  and  inflammation  about  the 
stricture.  Dilatation  and  thinning  of  the 
urethral  walls  behind.  Hypersecretion  and 
gleet.  Ulceration  may  take  place,  followed 
by  extravasation,  abscesses,  and  fistulfe. 
From  constant  straining  the  bladder  be- 
comes thickened,  hypeitrophied  and  sac- 
culated. The  urine  is  retained  and  fer- 
ments ;  cystitis  may  reach  a  high  grade. 
The  inflammation  passes  along  the  ureters, 
involves  the  pelves  of  the  kidneys,  and 
may  cause  death  by  suppurative  pyelitis 
or  nephritis. 

What  are  the  symptoms  of  organic 
stricture  of  the  urethra  ? 
Gleety  discharge,  especially  in  the  morn- 
ing ;  increased  frequency  of  urination,  with 
some  pain  ;  twisting,  forking,  or  diminu- 
tion in  the  size  of  the  stream.  Retention 
may  be  the  first  and  only  sign.  Later 
symptoms  are  due  to  involvement  of  other 
organs ;  haemorrhoids  frequently  result 
from  constant  straining. 

How  do  you  diagnose  strictures  ? 

By  ea-.amination  of  the.  urethra  with  hul- 
hous  hougies  or  the  iirethrometer.  Com- 
mence with  a  medium-sized  bulbous  bougie 
and  increase  the  size  till  decided  resistance 
is  experienced ;  or,  if  the  first  tried  will 
not  pass,  diminish  the  size  till  one  finally 
enters  the  bladder,  marking  on  its  stem 
the  point  where  resistance  begins  ;  slowly 
10 


Fig.  71. 


Bulbous 
Bougie. 


Urethrometer. 


146  ESSEN!flALS  OV  SURGICAL  DRESSlNa. 

withdraw  from  the  bladder,  marking  again  the  point  where  resistance 
begins  ;  this  will  give  both  the  calibre  and  the  width  of  the  stricture. 
If  the  obstiTiction  is  more  than  seven  inches  from  the  meatus,  it  is 
probably  due  to  an  enlarged  prostate.  The  possibility  of  spasm  or 
the  catching  of  the  bulb  of  the  bougie  in  a  lacuna  or  at  the  triangular 
ligament  must  be  home  in  mind. 

What  special  points  must  be  observed  in  passing  a  bougie  or 
catheter  ? 

See  that  the  instrument  is  clean,  smooth,  and,  if  it  is  a  catheter, 
pervious.  Warm  and  oil,  place  the  patient  on  his  back  with  thighs 
flexed,  bear  in  mind  the  course  of  the  urethra,  keep  the  catheter  in 
the  middle  line,  stretch  the  penis  forward  and  upward,  and  use  no 
force. 

What  difficulties  may  occur  in  passing  the  catheter  ? 

It  may  catch  in  a  fold  of  mucous  membrane,  or  in  a  lacuna. 
Avoid  by  keeping  the  point  on  the  floor  of  the  urethra  at  first,  then 
along  its  roof  It  may  catch  where  the  urethra  enters  the  triangu- 
lar ligament.  Withdraw  a  little,  and  keep  the  point  of  the  instni- 
ment  along  the  roof  of  the  urethra.  It  may  make  a  new  false 
passage,  or  enter  one  already  made,  denoted  by  a  sudden  slipping 
of  the  instrument,  pain,  and  detection  of  the  point  of  the  catheter 
outside  of  the  urethra  b}^  rectal  examination.  The  handle  of  the 
bougie  is  deflected  from  the  middle  line,  no  urine  escapes,  the  point 
is  not  freely  movable,  and,  if  the  false  passage  is  recent,  there  will 
be  free  bleeding. 

How  do  you  treat  false  passage  ? 

Withdraw  the  instmment  at  once,  and  make  no  further  effort  to 
pass  it  for  one  or  two  weeks.  Infiltration  of  urine  rarely  takes  place, 
the  false  passage  healing  promptly. 

What  constitutional  effects  may  foUow  the  passage  of  an 
instrument  ? 
Haematuria,  due  to  reflex  congestion,  syncope,  rigors,  urethral 
fever,  suppression  of  urine,  pyaemia. 

How  may  the  dangers  from  these  sequelae  be  lessened  ? 

Render  the  urine  antiseptic  by  the  administration  of  salol,  gr.  x, 
t.  L  d. ,  for  two  days  before  treatment. 


GONORRttdEA.  147 

Pass  tlie  instrument  with  the  patient  in  the  recumbent  position  ; 
give  twelve  grains  of  quinine  an  hour  before  treating  ;  inject  ten  to 
twenty  minims  of  a  1  per  cent,  solution  of  cocaine  into  the  bulbous 
portion  of  the  urethra,  by  means  of  the  prostatic  sjT-inge,  a  few 
minutes  before  passing  an  instrument.  Keep  the  patient  in  bed  sik 
to  twenty-four  hours  after  the  instmment  is  used. 

Fig.  72. 


N 


Filiform  Bougies. 

How  are  strictures  treated  ? 

Strictures  are  treated  by  dilafation,  urethroto7ny,  eocdsicm,  or  electro- 
lysis.    Dilatation  may  be  intermittent^  continuous,  or  rapid. 
Lhetlirotomy  or  cutting  may  be  either  external  or  internal. 

How  do  you  get  through  a  tight  stricture  ? 

The  patient  may  be  previously  relaxed,  before  attempting  instni- 

FlG.  73. 


Filiform  Threaded  upon  a  Railroad  Catheter. 

mentation,  by  a  warm  bath  and  a  hj^podermic  of  morphia  injected 
into  the  perineum.  A  small,  soft,  well-oiled  catheter  should  first  be 
inserted. 

If  this  fails  a  small  steel  sound  may  be  made  to  enter  the  bladder. 

If  still  unsuccessful,  a  number  of  filiform  bougies  may  be  intro- 
duced into  the  urethra  as  far  as  they  will  go  ;  each  bougie  is  then  in 


148  ESSENTIALS  OP  SURGICAL  DRESSING. 

turn  manipulated,  an  eiFort  being  made  to  guide  it  past  the  stricture. 
Patience  and  j)erseverance  in  this  method  nearly  always  result  suc- 
cessfully. The  railroad  catheter  may  then  be  threaded  upon  the 
extremity  of  the  filiform  which  has  entered  the  bladder,  and  maj^  be 
forced  through  the  stricture  without  fear  of  making  a  false  passage. 
If  it  is  not  considered  desirable  to  dilate  the  stricture  immediately 
the  filiform  may  be  allowed  to  remain  in  place  twenty -four  hours, 
when  sufficient  softening  of  the  stricture  will  have  taken  place  to 
allow  the  passage  of  a  small  catheter.       ' 

Describe  intermittent  dilatation. 

In  treating  a  stricture  b}^  dilatation  it  is  necessary  to  restore  the 
urethral  canal  to  its  normal  calibre.  Partial  stretching  of  the  stric- 
ture is  of  little  avail,  excepting  that  it  relieves  the  most  immediate 
and  distressing  symptoms.  The  calibre  of  the  urethra  varies  in 
accordance  with  the  size  of  the  penis.  If  the  circumference  of  the 
middle  of  the  organ  is  three  inches  a  French  sound  No.  30  will  be 
required  to  accomplish  full  dilatation  ;  3?  inches  requires  a  32  ;  3J, 
34  ;  3|,  36  •  4,  38,  and  over  4  No.  40. 

The  seat  and  calibre  of  the  stricture  are  first  determined  by  means 
of  the  urethrameter,  or  by  bulbous  bougies.  The  patient  is  instructed 
to  urinate,  and  is  placed  on  his  back  with  the  thighs  flexed.  The 
largest  flexible  bougie  which  can  be  passed  through  the  narrowings 
is  introduced  and  allowed  to  remain  for  two  minutes.  In  three 
days  the  patient  returns,  and  a  larger  instrument  is  introduced,  the 
surgeon  rarely  mnniug  up  more  than  four  numbers  at  a  single  sitting. 
This  treatment  should  be  continued  until  the  urethra  readilj''  receives 
a  sound  corresponding  to  its  normal  calibre,  and  the  patient  is  then 
instmcted  to  return  once  in  two  months  for  a  year,  lest  the  stricture 
should  in  the  meantime  contract.  Thereafter  the  passage  of  a  sound 
once  in  three  or  four  months  will  usually  be  sufficient  to  prevent  a 
recurrence  of  the  pathological  condition. 

In  passing  sounds  it  is  customary  to  run  up  two  numbers  at  a 
time,  thus,  if  No.  16  is  readily  received,  No.  18  is  next  introduced, 
and  next  No.  20.  Soft  rubber  bougies  are,  in  general,  safer  instru- 
struments  than  steel  sounds.  The  latter,  however,  can  be  very 
thoroughly  cleaned,  and  are  more  directly  under  the  control  of  the 
surgeon.     In  some    cases,   where  there  is  marked    spasm,   it  is 


OS 


150 


ESSENTIALS   OF  SURGICAL  DRESSING. 


impossible  to  pass  a  rubber  bougie.  In  passing  sounds  the  first 
precaution  to  observe  is  tliat  the  instruments  shall  be  thoroughly 
cleaned.     This  is  accomplished  by  dipping  them  in  alcohol  and 


Fig.  75. 


Fig.  76. 


Fig.  77. 


30 


ffj  S0N5. 


Soft  Rubber  Bougie. 


Steel  Sound. 


10^ 


Meatus  Bougie. 


igniting  the  latter,  this  superficial  flaming  not  destroying  the  temper 
of  the  instrument,  and  nevertheless  rendering  the  surfaces  perfectly 
sterile.     The  sound  is  then  dipped  in  five  j)er  cent,  carbolic  oil,  and 


GONORRHOEA.  151 

is  passed  gently  into  the  urethra.  The  surgeon  stands  to  the  right 
of  the  patient,  holds  the  penis  in  his  left  hand,  and  places  the 
blunt  extremity  of  the  sound  in  the  meatus.  As  soon  as  it  has 
entered  to  the  depth  of  two  inches  the  handle  of  the  instrument  is 
carried  toward  the  linea  alba  until  it  lies  parallel  with  that  line  and 
with  the  plane  of  the  hypogastric  portion  of  the  belly.  The  sound 
is  then  gently  pressed  into  the  urethra  to  the  depth  of  6  to  7  inches, 
when  its  extremity  will  have  reached  the  membranous  part,  and 
will  enter  no  farther.  The  handle  is  now  elevated  until  it  stands  at 
right  angles  to  the  plane  of  the  hypogastrium.  As  this  movement 
is  effected  the  instrament  enters  the  membranous  portion  of  the 
urethra ;  it  is  passed  on  into  the  bladder  by  depressing  the  handle 
between  the  legs. 

Describe  continuous  dilatation. 

The  patient  is  put  to  bed,  a  flexible  catheter  is  passed  thi'ough  the 
strictui'e  into  the  bladder,  and  is  allowed  to  remain  one  or  two 
days.  It  is  then  replaced  by  a  large  instrament.  This  method  is 
continued  until  the  stricture  is  dilated  up  to  the  normal  caHbre  of 
the  urethra. 

Tinder  what   circumstances  may  continuous  dilatation  be 
employed  ? 

Where  there  is  very  great  difficulty  in  introducing  an  instrument ; 
where  the  stricture  is  imtable  or  contractile,  and  there  are  objections 
to  the  performance  of  internal  urethrotomy. 

Describe  internal  urethrotomy. 

The  instruments  requhed  are,  in  the  first  place,  the  urethrameter, 
to  determine  the  exact  seat  and  extent  of  the  strictures,  and  a  knife 
by  which  the  latter  may  be  divided  without  injury  to  other  portions 
of  the  mucous  membranes  of  the  urethra.  These  indications  are 
met  by  the  Gerster  dilating  urethrotome,  which  keeps  the  part 
upon  the  stretch  while  it  is  being  cut,  and  which  enables  the  surgeon 
to  determine  when  the  normal  calibre  of  the  ui*ethra  has  been 
reached. 

The  patient  should  be  prepared  as  for  any  surgical  operation,  by 
attention  to  the  condition  of  the  stomach  and  bowels  for  a  few  days. 
In  addition  ten  grains  of  salol  should  be  given  three  times  daily  for 


152 


ESSENTIALS   OF  SURGICAL  DRESSING. 


Fig.  li 


Gerster  Dilating  Urethrotome. 


two  days.  When  from  neiTOus  temjDera- 
iiient,  chronic  inflammation  of  the  urethra, 
or  diseased  kidneys,  there  is  reason  to  fear 
urethral  fever,  twelve  grains  of  quinia  may 
be  given  four  hours  before  the  operation. 
The  urine  should  be  examined.  A  most 
careful  diagnosis  of  the  seat  and  extent  of 
the  strictures  should  be  made.  The  meatus 
must  be  either  dilated,  or  divided  along 
its  floor  until  it  admits  an  instrument  of 
the  normal  calibre  of  the  urethra.  The 
stricture  should  be  completely  divided 
along  the  roof  of  the  urethra,  exactly  in 
the  middle  line.  The  free  bleeding  which 
occurs  usually  stops  spontaneously  in  a 
few  minutes.  If  it  continues  a  bandage 
may  be  applied  to  the  penis,  or  if  this 
fails,  a  soft  catheter  may  be  passed  till  its 
extremity  lies  just  beyond  the  seat  of 
operation,  and  the  bandage  may  then  be 
applied.  When  the  bleeding  is  from  the 
deep  urethra,  firm  pressure  against  the 
perineum  is  indicated.  For  several  nights 
after  operation  the  patient  should  be 
watched,  as  dangerous  bleeding  may  take 
place  from  erection  occurring  in  sleep.  On 
the  second  day  after  operation,  a  full-sized 
sound  is  very  gently  passed  to  just  beyond 
the  seat  of  operation.  This  is  repeated 
every  third  day  till  the  parts  are  entirely 
healed. 

What  are  the  indications  for  internal 
urethrotomy  ? 

Internal  urethrotomy  is  applicable  to 
all  chronic  strictures  in  the  pendulous 
portion  of  the  urethra.  This  operation  is 
especially  indicated  when  the  stricture  is 


SYPHILIS.  153 

densely  indurated  and  cartilaginous,  and  when  it  does  not  yield  to 
gradual  dilatation,  or  quickly  relapses  when  treatment  is  suspended, 
also  when  it  is  impossible  for  the  patient  to  devote  the  time  neces- 
sary for  the  cure  of  stricture  by  gradual  dilatation,  and  when,  every 
time  a  bougie  is  passed,  there  is  a  marked  tendency  to  the  occurrence 
of  urethral  fever. 

What  is  the  ultimate  prognosis  in  internal  urethrotomy  ? 

Internal  urethrotomy,  if  properly  performed,  usually  results  in  a 
complete  and  permanent  cure  of  the  stricture.  Periurethral  ab- 
scesses, chordee  and  other  complications  are  rare. 

What  strictures  call  for  external  urethrotomy  ? 

Dense  cartilaginous  strictures  in  the  membranous  portion  of  the 
urethra,  or  imtable  and  contractile  strictures  in  the  same  region, 
especially  when  complicated  by  perineal  fistulas. 


Syphilis. 

What  is  syphilis  ? 

Syphilis  is  a  constitutional  disease  due  to  inoculation  with  specific 
virus. 

What  is  the  primary  lesion  of  syphilis  ? 

The  chancre. 

What  is  the  period  of  primary  incubation  ? 

The  time  which  elapses  between  exposure  to  contagion  and  the 
appearance  of  a  chancre.  It  is  usually  from  two  to  three  weeks, 
rarely  more  than  five  weeks. 

What  is  the  period  of  secondary  incubation  ? 

The  time  between  the  appearance  of  chancre  and  the  development 
of  secondary  symptoms.  These  rarely  appear  before  the  first  or 
after  the  third  month  succeeding  the  chancre. 

When  do  tertiary  symptoms  appear  ? 

At  a  period  varying  from  a  few  months  to  many  years  after  the 
secondaries. 

Describe  the  chancre  or  primary  sore. 

The  Chancre  is  commonly  found  about  the  corona  glandis,  but  it 


154  ESSENTIALS  OF  SURGICAL  DRESSING. 

may  appear  on  any  portion  of  the  body.  It  is  contracted  directly 
by  contact  with  chancre,  or  secondaries  (mucous  patches) ;  indirectly^ 
from  articles  used  by  syphilitics.  It  appears  as  an  indurated  pai)ule, 
which  develops  into  an  abrasion,  tubercle,  or  ulcer. 

What  are  the  characteristics  of  the  primary  sore  ? 

Indurated  base. 

Thin,  scanty  secretions. 

Inflammation  slight  around  the  sore. 

Usually  single. 

Not  auto-inoculable. 

Accompanied  by  polyganglionic,  painless  buboes,  which  rarely  sup- 
purate. 

Appears  after  an  incubation  period,  and  is  followed  by  secondary 
eruptions. 

The  Hiinterian  chancre  is  characterized  by  greater  depth,  free 
discharge,  and  more  marked  induration. 

The  mixed  chancre  exhibits  the  peculiarities  of  both  syphilitic 
and  chancroidal  inflammation,  and  is  due  to  simultaneous  inoculation 
with  both  forms  of  vims. 

What  is  the  prognosis  of  chancre  ? 

A  sore  exhibiting  the  typical  characteristics  of  chancre  is  nearly 
always,  but  not  invariably,  followed  by  secondary  eniptions.  The 
chancre  rarely  produces  extensive  destmction  of  tissues  and  usually 
undergoes  spontaneous  cure. 

What  is  the  treatment  of  chancre  ? 

The  sore  should  be  washed  several  times  daily  with  black-wash, 
and  dusted  with  calomel,  subiodide  of  bismuth,  iodol,  or  iodoform. 
Mercury  treatment  should  not  be  begun  until  the  secondaries  appear. 

What  symptoms  denote  that  the  disease  wiU  assume  a  severe 
type  ? 

Extensive  and  persistent  induration  of  the  chancre. 

General  and  marked  enlargement  of  the  lymphatic  glands.  Ap- 
pearance of  the  secondary  eruption  before  the  seventh  week 

Describe  the  secondary  lesions. 

Greneral  enlargement  of  the  lymiihatic  glands. 


SYPHILIS.  155 

Erui^tions  of  the  skin  and  mucous  membranes  ;  at  times  inflam- 
mation of  the  iris  or  periosteum,  and  falling  out  of  the  hair. 

Pathologically,  these  eruptions  are  at  first  due  to  congestion, 
which  is  followed  by  small,  round-celled  infiltration.  This  in  turn 
may  result  in  ulceration. 

The  development  of  secondaries  is  preceded  by  general  malaise, 
fever,  and  anemia,  lasting  a  few  days  and  disappearing  on  the 
appearance  of  roseola  and  sore  throat. 

The  skin  erujDtion  may  simulate  the  various  forms  of  skin  disease. 
It  may  be  erythematous  (s.  roseola),  papular  (s.  lichen),  vesicular 
(s.  herpes,  eczema,  and  varicella),  bullous  (s.  pemphigus),  or  pustu- 
lar (s.  ecthyma,  acne,  or  variola). 

The  mucous  membrane  lesions  are  pathologically  identical  with 
those  of  the  skin.  There  is  first  congestion  and  infiltration  (syphilitic 
sore  throat),  this  is  followed  by  maceration  of  the  epithelium  (mucous 
patches),  finally  ulcers  result. 

What  are  the  characteristics  of  syphilitic  skin  eruptions  ? 

Absence  of  itching. 

Symmetrical  arrangement  (on  the  two  sides  of  the  body). 
E,eddish-brown  or  coppery  color  (raw  ham). 
PolymorjDhous  (many  kinds  of  eruption  at  the  same  time). 
Therapeutic  test  (use  of  mercuiy). 

Describe  the  mucous  patch. 

Synonyms. — Condyloma  ;  mucous  tubercle. 

Pathology. — A  congested,  infiltrated  macule,  the  surface  of  which 
is,  from  its  peculiar  position  (upon  mucous  membrane,  about  the 
anus,  on  the  scrotum,  in  the  gluteal  folds),  continually  moist,  in 
consequence  of  which  the  epithelium  becomes  sodden. 

Appearance. — A  somewhat  elevated,  flat  macule,  covered  with  a 
dirty  whitish,  offensive  exudation. 

Give  the  treatment  of  secondary  syphilis. 

Mild  forms  of  the  disease  are  said  to  have  a  natural  tendency 
toward  spontaneous  resolution.  Where  the  patient  is  of  a  vigorous 
constitution  and  is  willing  to  submit  to  persistent  surface  eruptions 
the  treatment  may  be  purely  expectant,  every  attention  being  paid 
to  general  hygiene,  and  no  specific  medication  being  administered  for 


156  ESSENTIALS   OF   SURGICAL  DRESSING. 

the  eradication  of  the  disease.  When  practicable,  nine  or  twelve 
months  camping  out  may  enable  the  patient  to  thoroughly  eradicate 
the  syphilitic  taint. 

If  the  disease  is  severe  in  type,  or  attacks  persons  not  previously  m 
the  enjoyment  of  good  health,  vigorous  medication  will  be  required. 
The  only  drugs  which  seem  to  act  powerfully  upon  the  syphilitic 
lesions  are  iodine,  iodide  of  potassium  and  mercury.  Of  these  mer- 
cury seems  to  be  most  efficacious  during  the  secondary  period  of  the 
disease.     It  may  be  given  in  various  forms  and  by  various  methods. 

The  protiodide  of  mercury  is  the  form  in  which  the  drug  is  usually 
administered  ;  of  this  a  quarter  of  a  grain  is  given  three  times  a  day 
as  soon  as  the  early  secondaries  (enlargement  of  the  lymphatic 
glands,  mucous  patches,  etc. )  make  it  positive  that  the  patient  is 
infected  with  syphilis. 

Every  other  day  this  quantity  is  increased  by  one  quarter  of 
a  grain,  the  drug  being  administered  in  pill  form ;  the  quantity 
given  is  steadily  increased  until  the  constitutional  effects  of  mercury 
are  i^roduced.  When  protiodide  is  administered  the  first  effects 
of  the  drug  are  frequently  manifested  by  two  or  three  painful, 
watery,  alvine  evacuations.  If  the  drug  is  still  continued  the 
offensive  breath  and  beginning  mouth  tenderness  of  ptyalism  will 
next  be  noticed.  The  daily  quantity  must  then  -be  cut  down  one 
half,  and  continued  for  eighteen  months  unless  new  symptoms 
appear,  when  the  dose  may  be  temporarily  increased. 

After  eighteen  months  iodide  of  potassium,  from  five  to  ten  grains 
three  times  a  day,  is  given  in  addition  to  the  regular  quantity  of 
mercury.  This  mixed  treatment  is  continued  for  six  months  or  a 
year.  The  patient  may  then  be  allowed  to  discontinue  treatment. 
In  the  meantime  he  is  kept  carefully  under  observation  for  the 
detection  of  any  new  manifestation  of  the  disease.  If  such  mani- 
festations appear  the  mixed  treatment  must  be  resumed  and  con- 
tinued from  four  to  twelve  months.  During  the  latter  part  of  this 
prolonged  treatment  the  mercury  may  be  suspended  and  the  iodide 
of  potassium  alone  administered. 

In  case  the  protiodide  pills  produce  disorder  of  the  stomach  or 
bowels  before  they  can  be  taken  in  sufficient  quantity  to  modify  the 
manifestations  of  the  disease,  a  small  quantity  of  watery  extract 
of  opium  may  be  administered. 


SYPHILIS.  157 

At  times  it  will  be  found  that  protiodide  causes  much  irritation, 
even  when  opium  is  added,  and  that  it  is  impossible  to  give  it  in 
sufficient  dose.  In  this  case  the  form  of  mercury  can  advantageously 
be  changed.     The  following  formula  is  a  veiy  excellent  one. 

R.     Mass.  hydrarg.,  .    , gr.  ij 

Ferr.  sulpli.  exsiecat,, gT.  j-  M. 

Ft.  pill  No  1. 

SiG. — 1  t.  i.  d.=     Increase  as  required. 

When  iodide  of  potassium  is  added  to  the  mercury  it  is  con- 
venient to  administer  these  two  drugs  together.  The  following 
prescription  may  then  be  employed  : — • 

R.     Hydrarg.  chlor.  conos., gr.  iss-iij 

Potass,    iodid., ^iv-viij 

Syrup,  zingib., f^iij 

Aquoe,         q.  s fl'^'j-  ^I- 

SiG. — Teaspoonful  in  water  three  times  a  day. 

If  the  iodide  is  administered  alone  it  should  be  ordered  in  the  form 
of  the  saturated  solution. 

R .     Potassium  iodide, ,^  j 

Distilled  water,  q.  s.,     .    .  ad     .    .  Jj-  M. 

Each  minim  contains  1  grain ;  the  required  number  of  minims 
should  be  taken  in  milk,  which  disguises  the  taste  of  the  iodide 

During  the  course  of  the  mercury  treatment  it  is  most  important 
to  maintain  the  general  health  of  the  patient.  Tonics,  such  as 
quinine,  iron  and  cod-liver  oil  should  be  administered,  unless  they 
have  a  tendency  to  disorder  the  stomach.  The  life  of  the  patient 
should  be  most  carefully  regulated  in  accordance  with  hygienic 
rules.  Stimulants,  if  used  at  all,  must  be  taken  in  extreme  modera- 
tion and  with  food. 

At  times  no  form  of  mercury  can  be  taken  by  the  mouth  ;  it  may 
then  be  administered  by  inunction,  by  vaporization,  or  by  Jiypo- 
dermic  tnedication. 

When  given  by  {nunction,  the  patient  is  instructed  to  take  a  warm 
bath  in  the  evening  on  retiring.  One  drachm  of  mercury  ointment 
is  then  rubbed  for  fifteen  minutes  into  the  inner  surface  of  the 
arm  and  forearm,  and  the  corresponding  side  of  the  chest.     A  silk 


158  ESSENTIALS  Of  SURGICAL  3)EESSIN(3, 

or  flannel  undersliirt  is  next  donned,  and  tlie  patient  puts  on  liis 
ordinary  night  garments.  This  undershirt  must  be  worn  for  one 
week.  The  next  night  the  rubbing  is  repeated  as  before,  but  upon 
the  opposite  side  of  the  body.  The  following  night  the  omtment  is 
nibbed  into  the  left  groin  and  the  inner  surface  of  the  left  leg  and 
thigh  ;  next  into  the  right  groin,  leg  and  thigh,  and  the  fifth  night 
into  the  surface  of  the  belly  and  anterior  portion  of  the  chest.  On 
the  sixth  night  a  warm  bath  is  taken,  after  which  the  ointment  is 
rubbed  in  as  upon  the  first  night. 

In  place  of  blue  ointment  the  oleate  of  mercury  may  be  employed, 
although  this  is  more  irritating  to  the  skin  than  the  mercury  oint- 
ment. A  very  convenient  method  of  practising  inunctions,  though 
not  so  prompt  in  effect  as  the  one  described  above,  is  that  advocated 
by  Sturgis. 

Before  starting  the  inunction  the  patient  is  directed  to  take  a  hot 
foot-bath ;  into  the  sole  of  the  right  foot  is  then  rubbed  a  half 
drachm  of  a  twenty  per  cent,  solution  of  oleate  of  mercury,  and  the 
next  night  a  similar  quantity  is  rubbed  into  the  left  foot ;  thus  alter- 
nating, the  mercury  is  rubbed  in  every  night.  The  same  stockings 
must  be  worn  continuously  for  one  week,  after  which  the  feet  are 
thoroughly  cleansed  and  the  treatment  is  intermitted  for  two  or 
three  days.  The  quantity  of  mercury  thus  rubbed  in  may  be  in- 
creased to  suit  the  requirements  of  the  case. 

When  it  is  not  practicable  to  give  mercury,  either  by  the  mouth 
or  in  the  form  of  inunction,  it  may  be  administered  in  the  form  of 
vaporization.  To  accomplish  this  the  patient  is  seated,  naked,  upon 
a  chair  and  surrounded  with  blankets,  the  head  only  being  left  out. 
Beneath  the  tent  thus  formed  is  placed  a  large  vessel  filled  with 
boiling  water.  After  the  skin  is  thoroughly  softened  by  means  of 
this  steam  bath,  from  half  a  drachm  to  a  drachm  of  calomel  is  placed 
upon  a  metal  dish  and  is  vaporized  by  the  heat  of  an  alcohol  lamp, 
the  whole  being  placed  beneath  the  chair,  and  the  vapor  being  pre- 
vented from  escaping  by  keeping  the  blankets  applied  closely  about 
the  patient's  neck.  In  fifteen  minutes  the  patient  is  wrapped  in  the 
blankets  which  have  formed  the  vapor  tent  and  is  put  to  bed.  These 
blankets  may  be  removed  in  from  half  an  hour  to  an  hour. 

When  other  means  of  introducing  mercury  are  not  available,  or 
when  it  is  particularly  important  that  an  immediate  effect  should  be 


gY:PHiLl§.  159 

produced,  tlie  drag  may  be  administered  liypodermically.  Both 
the  soluble  and  insoluble  preparations  of  mercury  are  employed, 
but  on  account  of  the  pain  and  local  inflammation  produced  by  the 
latter  the  former  are  greatly  to  be  preferred.  The  hypodermic  solu- 
tion ma}^  be  prepared  according  to  the  following  formula  : — 

R  .     Bichloride  of  mercury, gr,  iij 

Chloride  of  sodium, ^  ss 

Distilled  water, 5  x. 

SiG. — Ten  to  twenty  minims  of  this  may  be  injected  daily. 

In  regard  to  the  choice  of  method  by  which  mercury  can  be  intro- 
duced into  the  system,  there  is  little  doubt  but  that  inunctions  act 
most  powerfully  uj^on  the  manifestations  of  the  disease,  and  at  the 
same  time  are  less  likely  to  exert  the  deleterious  influences  of  the 
drug  upon  the  system. 

Where  a  quick  action  is  imperative,  the  hypodermic  medications 
should  be  employed.  Where  the  convenience  of  the  patient  is  con- 
sulted, however,  and  this  usually  governs  the  method  of  adminis- 
tering the  mercury,  it  may  be  given  by  the  mouth. 

Although  long-continued  treatment  is  ordinarily  advised,  many 
authorities  administer  drugs  only  till  the  symptoms  of  the  disease 
disappear,  and  then  discontinue  the  treatment  until  further  mani- 
festations justify  its  resumption.  Under  no  circumstances  should  a 
patient  be  salivated.  This  condition  distinctly  and  seriously  compli- 
cates the  natural  course  of  a  case  of  syphilis.  The  so-called  tonic 
doses  of  mercury,  that  is,  half  the  quantity  necessary  to  produce 
ihe  fi.rst  symptoms  of  ptyalism,  seem  to  exert  a  decidedly  beneficial 
effect  upon  the  blood  aside  from  the  specific  action  upon  the  syph- 
ilitic manifestations. 

In  addition  to  the  general  treatment  of  syphilis,  local  lesions  may 
be  materially  modified  by  tojDical  applications. 

The  rapid  disappearance  of  the  secondary  eruptions  appearing 
upon  the  hands  and  face  may  be  accomplished  by  the  use  of  heat. 
The  infected  portion  of  the  skin  may  be  covered  with  a  layer  of  lint 
wrung  out  in  hot  water  ;  to  this  is  applied  a  hot-water  bag.  This 
treatment  is  continued  for  half  an  hour,  and  is  repeated  three  times 
a  day. 

During  the  night  the  patient  may  wear  a  face  mask  smeared  with 


160  ESSENTIALS   OF  SURGICAL  DRESSING. 

oleate  of  mercury  three  to  five  per  cent,  or  witli  five  to  ten  per  cent, 
ointment  of  ammoniated  mercury.  Gloves  may  be  worn,  the  inner 
surfaces  of  which  are  coated  with  the  same  preparations. 

Mucous  patches,  if  found  on  the  skin,  should  be  washed  with  mild 
solutions  of  bichloride  of  mercury,  dusted  with  calomel,  and  kept  dry 
by  introducing  a  layer  of  absorbent  cotton  between  the  skin  surfaces. 
Mucous  patches  in  the  mouth  are  treated  by  astringent  gargles  such 
as  myrrh,  hydrastis  and  chlorate  of  potash.  Each  patch  should  be 
touched  with  the  solid  stick  of  nitrate  of  silver,  or,  by  means  of  a 
glass  rod,  with  the  acid  nitrate  of  mercurj^  The  pain  of  this  last 
application  may  be  prevented  by  the  previous  application  of  cocaine. 

Should  the  patient  become  salivated,  he  should  be  instracted  to 
rinse  out  the  mouth  many  times  each  hour  with  a  warm  solution  of 
chlorate  of  potash,  fifteen  grains  to  the  ounce.  Of  this  one  tea- 
spoonful  should  be  swallowed  daily.  To  this  chlorate  of  jDotash 
mouth-wash  may  be  added  belladonna,  one-half  a  drachm  to  the 
ounce,  and  tincture  of  myrrh.  No  effort  should  be  made  to  check 
the  diarrhoea,  since  this  is  one  of  the  waj^s  in  which  the  drug  is  eli- 
minated. Local  application  of  cocaine  to  the  gums  will  greatly 
relieve  the  sufi'erings  of  the  patient. 

Ulcerating  sypliilicles  are  cleansed  and  dressed  according  to  gen- 
eral surgical  j^rinciples. 

When  iodide  is  indicated  and  the  patient  cannot  tolerate  it,  iodine 
may  be  employed  in  its  jilace.  The  following  formula  may  be 
ordered : — 

R .     Tincture  of  iodine, ,^  ij 

Simple  syrup, ^ij. 

SiG. — A  teaspoonful,  diluted  with  water,  three  times  a  day  with 
meals,  to  be  increased  as  required. 

Describe  the  tertiary  lesions  of  syphilis. 

Between  the  secondaries  and  tertiaries  proper  there  are  certain 
symi^toms  which  sometimes  appear,  called  reminders.  Among  these 
are  skin  emptions,  enlargement  of  the  testicle,  choroiditis,  ulcera- 
tion of  the  tongue,  disease  of  the  arteries,  and  psoriasis  of  the 
palms. 

The  tertiary  lesion  of  syphilis  is  the  gumma.  This  has  no  ten- 
dency to  spontaneous  cure,  and  is  characterized  by  the  formation  of 


SYPHILIS.  161 

round-celled  infiltrations,  which  commonly  involve  the  surrounding 
tissues,  and  either  break  down  in  the  centre,  leaving  ulceration,  or  are 
absorbed,  leaving  a  fibroid  thickening  and  scarring  (sj^philitic  stric- 
ture of  oesophagus,  etc. ).  The  gumma  may  attack  the  periosteum, 
causing  nodes,  caries  or  necrosis  ;  the  cutaneous  or  mucous  surfaces, 
causing  ulcers  on  any  part  of  the  body.  These  ulcers  of  tertiaiy 
syphilis  are  symmetrical,  and  are  not  contagious. 

Give  the  treatment  of  tertiary  syphilis. 

Mercury  and  potassium  iodide,  or  iodide  of  potassium  alone  or 
combined  with  tonics.  Commence  with  ten  grains  of  potassium 
iodide  three  times  a  day,  gradually  increasing  the  dose  till  the 
desired  effect  is  accomplished.  During  the  course  of  the  iodide 
treatment  the  disappearance  of  symptoms  may  be  greatly  hastened 
by  mercury  inunctions,  twelve  of  these  being  given  at  a  time,  with 
intervals  of  one  or  two  weeks  between  each  course. 

What  are  the  characteristics  of  the  tertiary  nicer  ? 

A  tertiary  ulcer  begins  as  a  gumma  or  lump,  which,  when  it  breaks, 
exposes  a  gray  slough,  surrounded  by  granulation  tissue.  The  edges 
are  rounded  and  sharply  cut.  Other  signs  of  syphilis  can  be  found. 
The  affection  jdelds  to  specific  treatment.  The  gumma  frequently 
affects  the  leg,  causing  an  ulcer  ;  such  ulcers  are  commonly  found 
upon  the  upper  third  of  the  limb. 

What  is  meant  by  syphilitic  cachexia  ? 

When  syphilis  affects  persons  before  feeble,  or  weakened  by  struma 
or  debilitating  diseases,  it  frequently  assumes  a  malignant  form. 
Treatment  seems  only  to  aggravate  the  symptoms,  at  the  same  time 
producing  profound  anaemia.  The  viscera  undergo  serious  patho- 
logical alterations,  absorption  practically  ceases,  and  the  disease 
terminates  fatally.  In  these  cases  specific  constitutional  treatment 
is  worse  than  useless.  Tonics,  stimulants,  and  general  hygienic 
treatment  represent  all  that  can  be  done  for  the  patient. 

What  is  congenital  syphilis  ? 

Syphilis  transmitted  to  the  foetus  through  the  spermatozoa  of  the 
father,  or  the  ovum  of  the  mother. 

What  are  the  characteristics  of  congenital  syphilis  ? 

Manifestations  are  rare  before  four  to  six  weeks  after  birth  ;  then 
11 


162  ESSENTIALS  OF  SURGICAL  DRESSING. 

there  may  be  secondaries,  as  snuffles  or  coryza,  macular  or  papular 
eruptions,  mucous  patches,  ulcerations  about  the  mouth  and  hps 
(rhagades),  stomatitis,  which,  by  its  effect  upon  the  dental  sacs  of 
the  permanent  teeth,  causes  subsequent  development  of  Hutchinson's 
teeth.  After  some  years  tertiaries  develop.  These  commonly  take 
the  form  of  interstitial  keratitis,  and  gummatous  developments. 

Describe  Hutchinson's  teeth. 

The  upper  permanent  median  incisors  chiefly  show  this  lesion, 
which  consists  in  a  dwarfng  of  the  entire  tooth,  an  extreme  diminu- 
tion in  its  ti'ee  end,  and  a  narrowing  of  the  cutting  edge,  with  a 
central  notch  or  crescent. 

Give  the  treatment  of  hereditary  syphilis. 

This  is  conducted  upon  the  same  lines  as  is  the  treatment  of  ac- 
quhed  secondaries.  Mercury  is  best  given  by  inunction,  gr.  x  of 
unguent,  hydrarg.  being  nibbed  over  the  abdomen  and  covered  by 
the  belly-band  eveiy  night.  TThen  the  symptoms  disappear  mer- 
cury treatment  should  be  discontinued.  A  non-infected  woman 
should  not  be  allowed  to  suckle  a  sj^philitic  child.  The  tertiaries  are 
treated  by  mercmy ,  together  with  iodide  of  potassium  and  tonics. 

What  is  CoUes's  law  ? 

A  syphilitic  child  suckled  by  its  mother  will  not  infect  her,  though 
she  be  (apparently)  free  from  venereal  disease. 

This  is  because  she  is  already  infected  with  the  disease,  which 
attacks  her  in  a  latent  form. 


SYPHILIS.  163 


ANTISEPTIC  FORMULAE. 

"Watery  solutions. 

Bichloride  of  mercuiy, 1-1000-1-2000. 

For  making  solutions,  which  are  to  be  kept  for  some  length  of 
time,  sodium  chloride  should  be  added  in  quantity  equal  to  that  of 
the  bichloride. 

A  convenient  solution  for  preparing  lotions  of  the  strength  ordi- 
narily used  is  the  following  : — 

H.     Bichloride  of  mercury, 2 

Sodium  chloride,      1 

Dilute  acetic  acid, 1 

Water, 16.  M. 

This  makes  a  ten  per  cent,  bichloride  solution  ;  by  adding  water 
in  appropriate  quantity  1-1000  and  1-2000  solutions  are  readily 
made. 

The  watery  solutions  of  other  antiseptic  solutions  are  commonly 
used  in  the  following  strengths  : — 

Carbolic  acid, 1-20  or  1-40 

Salicylic  acid, 1-300 

Boric  acid, 1-30 

Chloride  of  ziuc, 1-10  or  1-20 

Permanganate, 1-1000 

Carbolized  oil, 1-10 

Iodoform  collodion, 1-10 

Creolin, 1-20  or  1-40. 


Ointments. 

Iodoform. 

R.     Iodoform, 5 

Vaseline, 30 

Oil  of  almonds,     o 10  M, 


164  ESSENTIALS   OF  SURGICAL  DRESSING. 

Boric  acid. 

Be.     Boric  acid, 3 

Paraffine,   . 10 

Vaseline,    ...,,., 5  M. 


INDEX. 


ABSCESS,  periurethral,  137 
Ammonia  as  rubefacient,  S 

vesication  by,  90 
Anaesthetics,  79 

cocaine,  85 

cold,  86 

chloroform,  80,  85 

ether,  80 

nitrous  oxide,  80 
Antiseptic  dressings,  75,  79 

formulae,  163 

operation,  77 
Antiseptics,  71 

bichloride  of  mercury,  71 

boric  acid,  74,  164 

carbolic  acid,  72 

chloride  of  zinc,  74 

creolin,  74 

iodoform,  73,  163 

peroxide  of  hydrogen,  74 
Artificial  respiration,  S3 

Howard's  method,  84 

Sylvester's  method,  83 

BALANITIS,  126 
Treatment,  137 
Bandages,  handkerchief,  51 

Barton's,  58 

of  extremities,  56 

of  head,  51 

of  trunk,  53 
four-tailed,  50 
many-tailed,  49 
plaster-of-Paris,  59 
roller,  17 

Barton's,  40 

crossed  of  perineum,  49 

Desault,  29 

figure-of-eight,  50 

Gibson's,  42 

of  head,  40 

of  lower  extremity,  35 

spiral  reversed,  20 

of  trunk,  27 

turns,  19 


Bandages,  roller,  upper  extremity,  22 
Velpeau,  27 

suspensory,  139 

T,  48 
Bichloride  of  mercury,  71,  163 
Bleeding,  92 
Boric  acid,  74,  164 

CACHEXIA,  syphilitic,  161 
Cantharides,  89 
Capsicum,  88 
Carbolic  acid,  72 
Catarrh,  urethral,  140 
Catgut,  75 

Catheter,  prostatic,  143 
Cautery,  91 
Chancre,  153 

Hunterian,  154 

treatment,  154 
Chancroid,  118 
Chloride  of  zinc,  74 
Chloroform,  80,  85 

vesication  by,  90 
Cocaine,  85 
CoUes'  law,  162 
Counter-irritation,  87 
Cowperitis,  138 
Creolin,  74 
Cupping,  93 

DEPLETION,  92 
Drainage,  77 
Dressings,  75 

antiseptic,  75 
Lister's  new,  76 

FOLLICULITIS,  127 
treatment,  137 
Fomentations,  87 
Fracture  dressings,  99 
clavicle,  100 
femur,  107 
forearm,  104 
hand,  107 


165 


166 


INDEX. 


Fracture  dressings,  humerus,  102 
leg,  110 
maxilla,  100 
patella,  109 
radius,  105 
ribs,  64 
scapula,  101 

GLEET,  110 
treatment,  142 
Gonococcus,  125 
Gonorrhcea,  124 
chronic,  140 
Gonorrhoeal  rheumatism,  128 

HOAVARD,  artificial  respiration,  84 
Hutchinson's  teeth,  162 
Hypodermics,  96 
accidents,  98 

IODOFORM,  73 
Issue,  90 


K 


NOTS,  64 

Kocher's  reduction  of  shoulder 
luxation,  113 


LEECHING,  94 
Luxation,  111 
ankle,  118 
elbow,  115 
hand,  116 
hip,  117 
jaw,  112 
knee,  117 
patella,  118 

semilunar  cartilages,  118 
shoulder,  112 
wrist,  115 

UC©US  patch,  155 
Mustard,  88 


M 


0 


PERATION,  antiseptic,  77 


PARAPHIMOSIS,  126 
treatment,  137 
Passage,  false,  146 
Phimosis,  126 

treatment,  137 
Peroxide  of  hydrogen,  74 


Plaster-of-Paris  bandage,  59 

jacket,  61 
Plasters,  adhesive,  62 
Posthitis,  126 
Pott's  fracture.  111 
Prostatitis,  127 

treatment,  138 


RHEUMATISM,  gonorrhoeal,  128 
Rubefacients,  87 


SCULTETUS  bandage,  49 
Seton,  91 
Silk,  75 
Sounds,  150 
Sponges,  74 
Strangury,  90 
Strapping,  62 

breast,  63 

ribs,  64 

testicle,  63 

ulcer,  64 
Stricture,  causes,  144 

diagnosis,  145 

treatment,  147 
Stupes,  turpentine,  87 
Sutures,  65 

Czerny,  69 

Lembert,  68 
Sylvester  artificial  respiration,  83 
Syphilis,  153 

congenita],  161 

lesions,  153,  154 

primary,  treatment,  154 

secondary,        "  155 

tertiary,  160 

TEETH,  Hutchinson's,  162 
Transfusion,  95 

ULCER,  syphilitic,  161 
Urethra,  124 

dilatation,  148 
Urethrometer,  145 
Urethritis,  125 
acute,  126 

anterior,  treatment,  130 
posterior,  treatment,  136 
Urethroscope,  141 
Urethrotomy,  internal,  151 
external,  153 


MEDICAL  AND  SURGICAL  WORKS 

PUBLISHED   BY 

W.    B.    SAUNDERS, 
No.  913  Walnut  Street,        -        -        Philadelphia. 


INDEX. 

American  Text-Book  of  Diseases  of  CHILDKE^' 

American  Text-Book  of  Practice 

American  Text-Book  of  Surgery 

Ashton's  Obstetrics  ...... 

Ball's  Bacteriology  ...... 

Brockway's  Physics   ...... 

Cerna's  Notes  on  the  Newer  Remedies    . 
Chapman's  Medical  Jurisprudence  and  Toxicology 
Cohen  &  Eshner's  Diagnosis      .... 

CrAGIN'S   GYNiECOLOGY  ..... 

Da  Costa's  Manual  of  Surgery 

De  Schweinitz's  Diseases  of  the  Eye 

Garrigue's  Diseases  of  Women 

Gross's  Autobiography       ..... 

Hare's  Physiology      ...... 

Hampton's  Nursing  :  Its  Principles  and  Practice 
Jackson  and  Gleason's  Diseases  of  Eye,  Nose,  and  Throat 
Keating's  Pronouncing  Dictionary  of  Medicine 
Keating's  How  to  Examine  for  Life  Insurance 

Martin's  Surgery 

Martin's  Minor  Surgery,  Bandaging,  and  Venereal  Diseases 

Morris'  Materia  Medica  and  Therapeutics 

Morris'  Practice  of  Medicine  .... 

Nancrede's  Anatomy  and  Manual  of  Dissection 

Nancrede's  Anatomy  ..... 

NoKRis'  Syllabus  of  Obstetrical  Lectures 

Powell's  Diseases  of  Children 

Saunders'  Pocket  Medical  Formulary 

Saunders'  Pocket  Medical  Lexicon 

Saunders'  Series  of  Manuals    .... 

Saunders'  Series  of  Question  Compends  . 

Sayre's  Practice  of  Pharmacy  ... 

Semple's  Pathology  and  Morbid  Anatomy 

Semple's  Legal  Medicine,  Toxology,  and  Hygiene 

Senn's  Syllabus  of  Lectures  on  Surgery 

Shaw's  Nervous  Diseases  and  Insanity    . 

Stelwagon's  Diseases  of  the  Skin    . 

Stevens'  Practice  of  Medicine 

Stevens'  Materia  Medica  and  Therapeutics    . 

Stewart  and  Lawrange's  Medical  Electricity 

Transactions  of  the- American  Climatological  Association 

ViERORDT   and    StUART'S    MeDICAL   DIAGNOSIS 

Wolff's  Chemistry     ...... 

Wolff's  Examination  op  Urine         .         • 

1 


For  Sale  by  Subscription  only. 


An  American  Text-Book  of  Surgery. 

Forming  One  Handsome  Royal  Octavo  Toliime  of  oyer  1200  pages 

(10  X  7  inches),  with  nearly  500  Wood-cuts  in  Text,  and  37 

Colored  and  Half-tone  Plates,  many  of  them  Engraved 

from  Original  Photographs  and  Drawings  furnished 

by  the  Authors. 

Price,  Clotli,  $7  net ;  Sheep,  $8  net ;  Half  Eussia,  S9  net. 

BY 

CHARLES   H.    BURNETT,  M.D.,  Emeritus  Professor  of  Otology,  Phila- 
delphia Polyclinic. 

PHINEAS  S.  CONNER,  M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Col- 
lege of  Ohio  and  Dartmouth  Medical  College. 

FREDERIC   S.    DENNIS,   M.D.,  Professor  of  Principles  and  Practice  of 
Surgery,  Bellevue  Hospital  Medical  College. 

WILLIAM  W.  KEEN,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefi'erson  Medical  College. 

CHARLES    B.    NANCREDE,  M.D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  University. of  Michigan. 

ROSWELL    PARK,  M  D.,  Professor  of 'Surgery,  Medical  Department  of 
the  University  of  Balfalo. 

LEWIS   S.    PILCHER,   M.D.,    Professor  of  Clinical  Surgery  in  the  New- 
York  Post-Graduate  School  and  Hospital. 

NICHOLAS  SENN,    M.D.,  Pfi.D.,  Professor  of  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College. 

FRANCIS  J.  SHEPHERD,  M.D.,  CM.,  Professor  of  Anatomy  and  Lecturer 
on  Operative  Surgery,  McGill  University,  Montreal,  Canada. 

LEWIS  A.   STIMSON,  B.A.,  M.D.,  Professor  of  Surgery  in  the  University 
of  the  City  of  New  York. 

WILLIAM  THOMSON,  M.D.,  Professor  of  Ophthalmology,  Jefferson  Med- 
ical College. 

J.  COLLINS  WARREN,  M.D.,  Associate  Professor  of  Surgery,  Harvard 
University. 

J.  WILLIAM  WHITE,  M.D.,  Ph.D.,  Professor  of  Clinical  Surgery,  Uni- 
versity of  Pennsylvania. 

EDITED  BY 

WILLIAM  W.  KEEN,  M.D.,  LL.D.,  and 
J.  WILLIAM  WHITE,  M.D.,  Ph.D. 

2 


The  want  of  a  text-book  which  could  be  used  by  the  practitioner 
and  at  the  same  time  be  recommended  to  the  medical  student  has 
been  deeply  felt,  especially  by  teachers  of  surgery.  Hence,  when" 
it  was  suo-gested  to  a  number  of  them  that  it  would  be  well  to  unite 
in  preparing  a  book  of  this  description,  great  unanimity  of  opinion 
was  found  to  exist,  and  the  gentlemen  before  named  gladly  con- 
sented to  join  in  its  production.  While  there  is  no  distinctive 
American  Surgery,  yet  America  has  contributed  very  largely  to 
the  progress  of  modern  surgery,  and  among  the  foremost  of  those 
who  have  aided  in  developing  this  art  and  science  will  be  found  the 
authors  of  the  present  volume.  All  of  them  are  teachers  of  surgery 
in  leading  medical  schools  and  hospitals  in  the  United  States  and 
Canada. 

Especial  prominence  has  been  given  to  Surgical  Bacteriology ;  a 
feature  which  is  believed  ito  be  unique  in  a  surgical  text-book  in 
the  English  language.  Asepsis  and  Antisepsis  have  received  par- 
ticular attention,  and  full  details  of  the  various  methods  of  disin- 
fecting instruments,  hands,  and  the  field  of  operations,  sutures,  etc., 
will  be  found.  The  text  is  brought  well  up  to  date  in  such  import- 
ant branches  as  cerebral,  spinal,  intestinal,  and  pelvic  surgery,  and 
the  most  important  and  newest  operations  in  these  departments  are 
described  and  illustrated. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors 
for  their  mutual  criticism  and  revision,  also  an  entirely  new  and 
original  feature  in  book-making.  The  book,  as  a  whole,  therefore, 
expresses  on  all  the  important  surgical  topics  of  the  day  the  con- 
sensus of  opinion  of  the  eminent  surgeons  who  have  joined  in  its 
preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations. 
Very  many  of  them  are  original  and  faithful  reproductions  of  pho- 
tographs taken  directly  from  patients  or  from  specimens,  and  the 
modern  improvements  in  the  art  of  engraving  have  enabled  the 
publishers  to  produce  illustrations  which  it  is  believed  are  superior 
to  those  in  any  similar  work. 


For  Sale  by  Subscription  only. 
^  TREA.TISE 

ON    THE 

Theory  and  Practice  of  Medicine. 

BY 

AMERICAN  TEACHERS. 

Edited  by  WILLIAM  PEPPER,  M.D.,  LL.D., 

Provost  and  Professor  of  the  Theory  and  Practice  of   Medicine  and  of  Clinical 
Medicine  in  the  University  of  Pennsylvania. 

To  be  Completed  in  Two  Handsome  Royal  Octavo  Volumes  of  about 

1000  pages  each,  with  Illustrations  to  Elucidate 

the  Text  wherever  Necessary. 

Price  per  vol.,  Cloth,  $5  net ;  Sheep,  96  net ;  Half  Russia,  $7  net. 


VO  L  TIME  I,  ( No  w  Heady)  contains : 

Hygiene. 

J.  S.  Billings,  Professor  of  Hygiene,  University  of  Pennsylvania. 

Feyers,  (Ephemeral,  Simple  Contiimed,  Typhus,  Typhoid,  Epidemic 
Cerebro-spinal  Meningitis,  and  Relapsing.) 

Wm.  Pepper,  M.D.,  Provost  and  Professorof  the  Theory  and  Practice 
of  Medicine  and  of  Clinical  Medicine,  University  of  Pennsylvania. 

Scarlatina,  Measles,  Rothelu,  Variola,  Varioloid,  Vaccinia,  Varicella, 
Mumps,  Whooping-cough,  Anthrax,  Hydrophobia,  Trichinosis, 
Actinomycosis,  Glanders,  and  Tetanus. 

James  T.  Whittaker,  M.D.,  Professor  of  the  Theory  and  Practice  of 

Medicine  and  of  Clinical  Medicine,  Medical  College  of  Cincinnati,  O. 

Tuberculosis,  Scrofula,  Syphilis,   Diphtheria,  Erysipelas,  Malaria, 
Cholera,  and  Yellow  Feyer. 

W.  Oilman  Thompson,  M  D.,  Professor  of  Physiology,  New  York 
University  Medical  College. 

Neryous,  Muscular,  and  Mental  Diseases  (Including  Opium  Habit,  etc.). 

Horatio  C.  Wood,  M.D.,  Professor  of  Materia  Medica,  Pharmacy,  and 
General  Therapeutics,  and  Clinical  Professor  of  Nervous  Diseases, 
University  of  Pennsylvania.    And 

William  Osler,  M.D.,  Professor  of  Practice  of  Medicine,  Johns  Hop- 
kins University,  Baltimore,  Md. 


VOLUME  II.  (Ready  Shortly)  will  contain: 

Urine  (Chemistry  and  Microscopy). 

James  W.  Holland,  M.D.,  Professor  of  Medical  Chemistry  and  Toxi- 
cology,  Jeflferson  Medical  College,  Philadelphia. 

Kidneys  and  Lungs. 

Francis  Delafield,  M.D.,  Professor  of  Pathology  and  Practice  of 
Medicine,  College  of  Physicians  and  Surgeons,  New  York  City. 

Air-passages  (Larynx  and  Bronchi)  and  Plenra. 

James  C.  Wilson,  M.D.,  Professor  of  Practice  of  Medicine  and  of 
Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

Pharynx,  (Esophagus,  Stomach,  and  Intestines  (Including 
Intestinal  Parasites). 

William  Pepper,  M.D.,  Provost  and  Professor  of  the  Theory  and  Prac- 
ticeof  Medicine  and  of  Clinical  Medicine,  Uniyersity  of  Pennsylvania. 

Peritoneum,  Liver,  and  Pancreas. 

Eeginald  H.  Fitz,  M.  D.,  Hersey  Professor  of  Physics,  Harvard  Medi- 
cal School. 

Diathetic  Diseases  (Rheumatism,  Rheumatoid  Arthritis,  Gout, 
Lithsemia,  and  Diabetes). 

Henry  M.    Lyman,   M.D.,   Professor  of  Principles  and  Practice  of 
Medicine,  Rush  Medical  College,  Chicago,  111, 

Heart,  Aorta,  Arteries,  and  Yeins. 

E.  G.  Janeway,  M.D.,  Professor  of  Principles  and  Practice  of  Medi- 
cine, Bellevue  Hospital  Medical  College,  New  York  City. 

Blood  and  Spleen. 

William  Osler,  M.D.,  Professor  of  Practice  of  Medicine,  Johns  Hop- 
kins University,  Baltimore,  Md. 

Inflammation,  Embolism,  Thrombosis,  Fever,  and  Bacteriology. 

W.  H.  Welch,  M.D.,  Professor  of  Pathology,  Johns  Hopkins  Uni- 
versity, Baltimore,  Md. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures, 
but  are  exhaustive  descriptions  of  diseases  witli  the  newest  facts  as  re- 
gards Causation,  Symptomatology,  Diagnosis,  Prognosis,  and  Treat- 
ment, and  will  include  a  large  number  of  approved  Formulae.  The  re- 
cent advances  made  in  the  study  of  the  bacterial  origin  of  various  dis- 
eases are  fully  described,  as  well  as  the  bearing  of  the  knowledge  so 
gained  upon  prevention  and  cure.  The  subjects  of  Bactwiology  as  a 
whole  and  of  immunity  are  folly  considered  in  a  separate  section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention, 
thus  enabling  the  reader  to  learn  the  very  latest  methods  of  investigation 
without  consulting  works  specially  devoted  to  the  subject. 

5 


IN  PREPARATION. 


For  Sale  by  Subscription  only. 


AN  AMERICAN  TEXT-BOOK 


DISEASES  OF  CHILDREN 

INCLUDING 

Special  Chapters  on  Essential  Surgical  Subjects ;  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat;  Diseases  of  the 

Skin ;  and  on  the  Diet,  Hygiene,  and  General 

Management  of  Children. 

BY 


EDITED  BY 

LOUIS    STAEE,  M.D., 

ASSISTED    BY 

THOMPSON   S.    WESTCOTT,  M.D. 


Forming  a  handsome  imperial  8vo.  vol.  of  about 
1000  pages,  profusely  illustrated. 


PHILADELPHIA  : 

W.    B.    SAUNDERS, 

913  WAL^■UT  Street, 
6 


AM  0  [IN  CEMENT. 


An  American  Text-book  of  the  Diseases  of  Children  will  be 
issued  as  a  handsome  imperial  octavo  volnrae  of  about  1000 
pages,  uniform  with  an  American  Text-book  of  Surgerj-,  con- 
taining numerous  wood-cuts,  half-tone  plates,  and  colored  illus- 
trations. The  plan  contemplates  a  series  of  original  articles 
written  by  some  sixt}^  well-known  psediatrists,  representing 
collectively  the  present  teachings  of  the  most  prominent  med- 
ical schools  and  colleges  of  America.  The  work  is  not  intended 
to  be  encj^clop?edic  in  character,  but  to  be  a  practical  book 
suitable  for  constant  and  handy  reference  by  the  practitioner 
and  advanced  student. 

One  decided  innovation  for  a  book  of  its  size  is  the  large 
number  of  authors,  nearly  ever}^  article  being  contributed  by 
a  specialist  in  the  line  on  which  he  writes.  This,  while  entail- 
ing considerable  labor  upon  the  editors,  has  resulted  in  the 
publication  of  a  work  thoroughly  new  and  abreast  of  the  times. 
The  entire  work  has  been  practically  written  in  a  few  months, 
thus  removing  the  usual  objection  to  treatises  of  this  class, 
that  they  are  out  of  date  before  the}^  are  published. 

Especial  attention  is  given  to  the  consideration  of  the  latest 
accepted  teaching  upon  the  Etiology,  Sj^mptoms,  Pathology, 
Diao'nosis,  and  Treatment  of  the  disorders  of  children,  with 
the  introduction  of  many  special  formulae  and  therapieutic 
procedures. 

Special  cha^^ters  embrace  at  unusual  leugth  the  diseases  of 
the  E^^e,  Ear,  Nose  and  Throat,  and  the  Skin  ;  while  the  intro- 
ductory chapters  cover  full}'  the  important  subjects  of  Diet, 
Hj-^giene,  Exercise,  Bathing,  and  the  Chemistr}'  of  Food. 
Tracheotomy,  Intubation,  Circumcision,  and  such  minor  sur- 
gical procedures  coming  within  the  province  of  the  medical 
practitioner  are  carefullj^  considered. 


For  Sale  by  Subscription  only. 
Now  Ready — Second  Revised  Edition. 

MEDICAL  DIAGNOSIS. 

By  dr.  OSWALD  YIERORDT, 

Professor  of  Medicine  at  the  University  of  Heidelberg ;  formerly  Privat  Decent 

at  University  of  Leipzig  ;   Professor  of  Medicine  and  Director 

of  the  Medical  Polyclinic  at  the  Univ.  of  Jena. 

Translated  with  additions,  from  the  Second  Enlarged  German  Edition, 
with  the  Author's  Permission. 

By  FRANCIS  H.  STUART,  A.M.,  M.D., 

Member  of  the  Medical  Society  of  the  County  of  Kings,   N.  Y.  ;  Fellow  of  the 

New  York  Academy  of  Medicine  ;  Member  of  the 

British  Medical  Association,   etc. 

In  One  Handsome  Royal  Octavo  Volume  of  700  Pages. 

178  Fine  Wood-cuts  in  Text,  Many  of  Which  are  In  Colors. 

Frice,  Cloth,  $4  net;  Sheep,  $5  net;  Half  Russia,  $5,50  net. 

This  Valuable  Work  is  now  Published  in  German,  English,  Eussian,  and  Italian, 
FIRST    AMERICAN    EDITION    EXHAUSTED   WITHIN   SIX   MONTHS. 


i^ii.OFBssio3sr-A.L  oi>iisrioisrs. 

'*  One  of  the  most  valuable  and  useful  works  in  medical  literature." 

(Signed)  ALEXANDER  J.   C.   SKENE,   M.D., 

Dean  of  the  Long  Island  College  Hospital^  and  Professor  of  the 

3Iedical  and  Surgical  Diseases  of  Women. 

"Indispensable  to  both  'students  and  practitioners.'  " 

.      (Signed)  F.  MINOT,  M.D., 

Hersey  Professor  of  Theory  and  Practice  of  Medicine,  Harvard  Unwersity. 

"It  is  very  well  arranged  and  very  complete,  and  contains  valuable  features 
not  usually  found  in  the  ordinary  books.  " 

(Signed)  J.  H.   MUSSER,   M.D., 

Assistant  Professor  Clinical  Medicine,  University  of  Pennsylvania. 

"  A  most  excellent  book  upon  a  most  important  subject.'" 

(Signed)  J.   S.   CAIN,   M.D., 

Pi'ofessor  of  Practice  of  3Iedicine  and  General  Pathology, 

Nashville  3fedical  College,  Nashville,  Tenn. 

*'  One  of  the  most  valuable  works  now  before  the  profession,  both  for  study  and 
reference."  (Signed)  N.  S.   DAVIS,  M.D., 

Professor  of  Principles  and  P-actice  of  Medicine  and 

Clinical  Medicine,  Chicago  Medical  College. 

"A  treasury  of  practical  information  which  will  be  found  of  daily  use  to  every 
busy  practitioner  who  will  consult  it. " 

(Signed)         C.   A.  LINDSLEY,  M.D., 

Professor  of  Theory  and  Practice  of  Medicine,  Yale  University,  New  Haven,  Conn. 


For  Sale  hy  Subscription  only. 


NOW   READY. 

DISEASES  OF  THE  EYE. 

A  Hand-Book  of  Ophthalmic  Practice, 

By  G.  E.  de  SCHWEIKITZ,  MD., 

Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic;  Professor  of  Clinical 

Ophthalmology,  Jefferson  Medical  College,  Philadelphia :  Ophthalmic  Surgeoa 

to  Children's  Hospital  and  to  the  Philadelphia  Hospital ;  0|)hthalinologist 

to  the  Orthopaedic  Hospital  and  Infiriuary  for  Nervous  Diseases;  late 

Lecturer  on  Medical  Ophthalmoscopy,  University  of  Pa.,  etc. 


Forming  a  handsome  royal  8vo.  vol.  of  more  than  600  pages. 

jr  200  fine  wood-cuts,  many  of  which  are  original,  and  i 
chromo-lithographic  plates. 

Price,  Oloth,  $4  net ;  Sheep,  $5  net ;  Half  Eussia,  $5,50  net. 


PROFESSIONAL  OPINIONS. 

"  A  work  that  will  meet  with  the  requirements  not  only  of  the  specialist,  but 

of  the  general  practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success 

awaits  it."  (Signed)  WILLIAM  PEPPER,  M.D., 

Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Iledicine 

in  the  University  of  Pennsylvania. 

' '  Contains  in  concise  and  reliable  form  the  accepted  vieAvs  of  Ophthalmic  Sci- 
ence." (Signed)  WILLIAM  THOMSON,   M.D,, 

Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia,  Pa. 

"  One  of  the  best  hand-books  now  extant  on  the  subject.  " 

(Signed)  J.  0.  STILLSON,  M.D., 

Professor  of  Eye  and  Ear,  Central  College  of  Physicians  and  Surgeons,  Indianapolis,  Ind. 

"Vastly  superior  to  any  book  on  the  subject  with  which  I  am  familiar." 
(Signed)  ERANGIS  HART  STUART,  M.D., 

Brooklyn,  N.  Y. 

"Contains  in  the  most  attractive  and  easily  understood  form  just  the  sort  of 
knowledge  which  is  necessary  to  the  intelligent  practice  of  general  medicine  and 
surgery."  (Signed)  J.   WILLIAM  WHITE,   M.D., 

Professor  of  Clinical  Surgery  in  the  University  of  Pennsylvania. 

"A  very  reliable  guide  to  the  study  of  eye  diseases,  presenting  the  latest  facts 
and  newest  ideas. "  (Signed)  SWAN  M.  BURNETT,  M.D., 

Prof,  of  Ophthalmology  and  Otology,  Med.  Department  Univ.  Georgetown^  Washington,  D.  C. 

9 


For  Sale  by  Subscription  only. 

A  NEW  PRONOUNCING 

DICTIONARY  OF  MEDICINE. 

WITH 

Phonetic  Pronnnciation,  Accentuation,  Etymology,  etc. 
By  JOHN  M.  KEATING,  M.D.,  LL.D., 

Fellow  of  the  College  of  Physicians.of  Philadelphia  ;  Vice-President  of  the  Amei-ican 

P^ediatric  Society ;  Ex-President  of  the  Association  of  Life  Insurance  Medical 

Directors:  Editor  "  Cycloj)a;dia  of  the  Diseases  of  Children,''  etc.  ; 

AND 

HENRY  HAMILTON, 

Author  of  "A  new  Translation  of  Virgil's  J^neid  into  English  Rhyme  :'* 
Co- Author  of  "  Saunders"  Medical  Lexicon,"  etc. 

WITH  AN  APPENDIX 

CONTAINING  IMPORTANT  TABLES  OF  BACILLI,  MICROCOCCI,  LEUCOMAINES, 

PTOMAINES  ;  DRUGS  AKD  MATERIALS  USED  IN  ANTISEPTIC  SURGERY  ; 

POISONS  AND  THEIR  ANTIDOTES;    WEIGHTS  AND  MEASURES  ; 

THERMOMETRIC  SCALES  ;   NEW  OFFICINAL  AND 

UNOFFICINAL  DRUGS,  ETC.  ETC. 

Forming  One  very  Attractive  Voiume  of  over  800  pages. 

Price, Clotli,  $5  net;  Sheep,  $6  net;  Half  Eussia,  $6.50  net. 

With  Denisou's  Patent  Index  for  Ready  Reference. 


"I  am  much  pleased  vrith  Keating's    Dictionary,  and  shall    take  pleasure  in 
recommending  it  to  my  classes. "       (Signed)       HEXRY  M.  LYMAjST,  M.D., 

Professor  of  Principles  and  Practice  of  Medicine,  Rash  Medical  College,  Chicago^  III. 

"I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study  table, 
convenient  in  size  and  sufficiently  full  for  ordinary  use." 

(Signed)         C.   A.   LINDSLEY,   M;D., 
Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  Universily, 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Connecticut. 

"I  will  point  out  to  my  classes  the  many  good  features  of  this  book  as  com- 
pared with  others,  which  will,  I  am  sure,  make  it  verv  popular  with  students.  ' 
(Signed)         JOHX  CRONYN,   M.D.,   LL.D., 
Professor  of  Principles  and  Practice  of  Medicine  and  Clinical  Medicine; 

President  of  the  Faculty,  Medical  Bept.  Niagara  University,  Buffalo,  N  Y. 

"  My  ^amination  and  use  of  it  have  given  me  a  very  favorable  opinion  of  its 
merit,  am  it  will  give  me  pleasure  to  recommend  its  use  to  mv  class."' 

(Signed)         J.   W.   H.  LOYEJOY,   M.D., 
Professor  of  Theory  and  Practice  of  Medicine,  and  President  of  the  Faculty, 

Medical  Depf.  Georgetown  University,  Washington,  D.  C. 
10 


Second  Edition,  for  Sale  by  Subscription. 

AUTOBIOGRAPHY 


OF 


SAMUEL  D.  GROSS,  M.D„ 

D.  C.  L.  OXON.,  LL.D.  CANTAB.,  EDIN.,  JEFFERSON  COLLEGE,  UNIV.  PA., 

EMERITUS  PROFESSOR  OF  SURGERY  IN  THE  JEFFERSON   MEDICAL 

COLLEGE  OP  PHILADELPHIA. 

WITH  REMmiSCENCES  OF 

HIS  TIMES  AND  CONTEMPORARIES. 

Edited  by  bis  Sons,  Samuel  W.  Gross,  M.D.,  LL.D.,  late  Pro- 
fessor of  Principles  of  Surgery  and  of  Clinical  Surgery  in  tbe 
Jefferson  Medical  College,  and  A.  Hauler  Gross,  A.M., 
of  tbe  Pbiladelpbia  Bar. 

Preceded  by  a  Memoir  of  Dr.  Gross  by  the  late  Austin  Flint,  M.D.,  LL.D. 

In  two  handsome  vols.,  eacli  containing*  over  400  pages, 

demy  8vo.,  ex.  clotli,  gt.  tops,  with  fine  Frontispiece 

engraved  on  steel. 

Price     .    .    .    $5.00  net. 

Tbis  Autobiography,  wbicb  was  continued  by  tbe  late  eminent 
Surgeon  until  witbin  tbree  montbs  before  bis  deatb,  contains  a 
full  and  accurate  bistory  of  bis  early  struggles,  trials,  and  subse- 
quent successes,  told  in  a  singularly  interesting  and  cbarm-ng  man- 
ner, and  embraces  sbort  and  grapbic  pen  portraits  of  many  of  tbe 
most  distinguisbed  men  —  surgeons,  pbysicians,  divines,  lawyers, 
statesmen,  scientists,  etc.  etc. — witb  wbom  be  was  brougbt  in  con- 
tact in  tbis  country  and  in  Europe ;  tbe  whole  forming  a  retrospect 

of  more  tban  three-quarters  of  a  century. 

n 


Pocket  Medical  Formulary 

BY 
WILLIAM  M.  POWELL,  M.D., 

Attending  Physician  to  the  Mercer  House  for  Invalid  Women,  at  Atlantic  City. 

COXTAIXIXG 

1750  Formulae,  selected  from  several  hundreds  of  the  best  known 

authorities. 

Forming  a  handsome  and  convenient  Pocket  Companion  of  nearly  300 
printed  pages,  and  blank  leaves  for  additions. 

WITH  AN  APPENDIX 

Containing  Posological  Table  :  Formulae  and  Doses  for  Hypo- 
dermic Medication;  Poisons  and  their  Antidotes ;  Diam- 
eters of  the  Female  Pelvis  and  Foetal  Head;  Obstet-  - 
rical  Table;  Diet  List  for  various  diseases ; 
Materials  and  Drugs  used  in  Antiseptic  Surgery ;  Treatment 
of  Asphyxia  from  Drowning;   Surgical  Remembrancer ; 
Tables  of  Incompatibles ;  Eruptive  Fevers ;  Weights 
and  Measures,  etc. 

Second  Edition,  Eevised  and  greatly  Enlarged. 

Handsomely  bound  in  Morocco,  with  Patent  Index,  Wallet,  and  Flap. 
Brice,  $1.75  net. 

Therapettic  Gazette,  January,  1892.— "  The  prescriptions  hare  been  taken 
from  the  writings  or  practice  of  Physicians  whose  experience  qualifies  them  to  be 
worthy  of  trial.  We  heartily  recommend  this  volume  to  all  who  desire  to  purchase 
such  a  work." 

Xew  York  Medical  Record,  February  27,  1892.  — "  This  little  book,  that  can 
be  conveniently  carried  in  the  pocket,  contains  an  immense  amount  of  material. 
It  is  very  useful,  and,  as  the  name  of  the  author  of  each  prescription  is  given,  is 
unusually  reliable." 

12 


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SERIES  OF  MANUALS 


FOR 


Students  and  Practitioners. 


The  aim  of  the  Pubhsher  is  to  furnish,  in  this 
Series  of  Manuals,  a  number  of  high-class  works 
by  prominent  teachers  who  are  connected  with  the 
j)rincipal  Colleges  and  Universities  oFthis  country; 
the  position  and  experience  of  each  being  a  guar- 
antee of  the  soundness  and  standard  of  text  of  the 
subject  on  which  he  writes. 

Especial  care  has  been  exercised  in  the  choice  of 
large,  clear,  readable  type ;  a  high  grade  of  slightly 
toned  paper,  of  a  shade  particularly  adapted  for 
reading  by  artificial  light;  high  class  illustrations, 
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tion jof  the  text ;  and  strong,  attractive,  and  uniform 
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being  considered  desirable  to  fix  an  arbitrary  stand- 
ard and  pad  the  volumes  accordingly. 


13 


Now  Ready — Fourtli  Edition, 

CONTAINING 


Essentials  of  Anatomy  and  Manual  of  Practical 

Dissection. 

B^  CHAELES  B.  KAKCREDE,  M.D., 

Professor  of  Surgery  and  Clinical  Surgery  in  tlie  University  of  Michigan,  Ann 

Arbor;  Corresponding  Member  of  the  Koyal  Academy  of  Medicine, 

Eome,  Italy ;  late  Surgeon  Jefi erson  Medical  College,  etc.  etc. 


With  Handseme  Full-page  Lithographic  Plates  in  Colors.    Over  200  Illustrations. 


No  pains  or  expense  has  been  spared  to  make  this  worlc  the  most  exhaustive 
yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  published,  either 
in  this  country  or  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  For  this  edition  the  woodcuts  have  all  been  speci- 
ally drawn  and  engraved,  and  an  Appendix  added  containing  60  illustrations 
representing  the  structure  of  the  entire  human  skeleton,  the  whole  based  on 
the  eleventh  edition  of  Gray's  Anatomy,  and  forming  a  Iiandsorae  post  8vo 
volume  of  over  400  pages. 


Price,  Extra  Cloth  or  Oilcloth  for  the  Dissection-Room,  $2.00  Net. 
Medical  Sheep, 2.50    " 


JUST  PUBLISHED. 


A  MANUAL 


OF    THE 


PRACTICE  OF  MEDICIIE. 

BT 

A.  A.  STEVENS,  A.M.,  M.D., 

Instructor  of  Physical  Diagnosis  in  the  University  of  Pennsylvania,  and 

Demonstrator  of  Pathology  in  the  Woman's  Medical  College 

of  Philadelphia. 

Post  8vo.,  502  pages.    Illustrated. 

Price,  Cloth $2.50 

W.  B.  SAUNDERS,  Publisher, 

PHILADELPHIA,  PA. 


Contributions  to  the  science  of  medicine  have  poured  in 
so  rapidly  during  the  last  quarter  of  a  century,  that  it  is  well 
nigh  impossible  for  the  student,  with  the  limited  time  at  his 
disposal,  to  master  elaborate  treatises,  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  ex- 
tended experience  in  teaching,  the  author  has  been  enabled 
by  classification,  the  grouping  of  allied  symptoms,  and  the 
judicious  elimination  of  theories  and  redundant  explanations, 
to  bring  within  a  comparatively  small  compass  a  complete 
outline  of  the  Practice  of  Medicine. 

15 


Now  Heady. 


A    MANUAL 


OF 


MEDICAL   JURISPRUDENCE 


AND 


TOXICOLOaY. 


BY 

HENEY  CHAPMAN,  M.D., 

Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  JeflFersoB 
Medical  College  of  Philadelphia  ;  Member  of  the  College  of  Physicians 
of  Philadelphia,  of  the  Academy  of  Natural  Sciences  of  Phila- 
delphia, of  the  American  Philosophical  Society,  and  of 
the  Zoological  Society  of  Philadelphia. 

232  pages.     Post-octavo. 
WITH  THIRTY-SIX  ILLUSTRATIONS, 

Some  of  which  are  in  Colors. 


Price,  $1.25  Net. 


For  many  years  there  has  been  a  demand  from  members  of  the 
medical  and  legal  professions  for  a  medium-sized  work  on  this  most 
important  branch  of  medicine.  The  necessarily  prescribed  limits 
of  the  work  permit  only  the  consideration  of  those  parts  of  this 
extensive  subject  which  the  experience  of  the  author  as  coroner's 
physician  of  the  city  of  Philadelphia  for  a  period  of  six  years  leads 
him  to  regard  as  the  most  material  for  practical  purposes. 
"^  Particular  attention  is  drawn  to  the  illustrations,  many  being 
produced  in  colors,  thug  conveying  to  the  layman  a  far  clearer  idea 
of  the  more  intricate  cases. 

16 


The  following  Manuals  now  preparing  will  be  Issued  Shortly. 


Nursing:  Its  Principles  and  Practice 

FOR  HOSPITAL  AND  PEIVATE  USE. 

By  ISABEL  ADAMS  HAMPTON, 

Graduate  of  the  New  York  Training  School  for  Nurses  attached  to  Bellevue 

Hospital;  Superintendent  of  Nurses  and  Principal  of  the  Training  School 

for  Nurses,  Johns  Hopkins  Hospital,  Baltimore,  Md. :  Late 

Superintendent  of  Nurses,  Illinois  Training  School 

for  Nurses,  Chicago.  Illinois. 

Price,  $2.00  net. 

This  book  will  outline  a  definite,  systematic  course  of  teaching  for 
pupil-nurses  with  a  thoroughness  that  nothing  previously  published  on 
the  subject  has  attempted ;  and  the  need  for  such  a  work  is  greatly  felt 
by  young  superintendents  when  taking  upon  themselves  the  responsi- 
bility of  training-school  work. 

Thoroughly  tested  and  most  approved  processes  are  given  in  all  the 
details  of  practical  nursing,  particularly  in  antiseptic  surgery,  and  the 
minutest  details  regarding  the  nurse's  technique  have  been  explained. 

The  methods  used  in  Johns  Hopkins  Hospital  have  in  all  cases  been 
noted  as  the  authority. 


A  SYLLABUS  OF  LECTURES 

ON    THE 

PRACTICE    OF    SUEGERY. 

ARRANGED    IN    CONFORMITY    WITH 

THE  AMERICAN  TEXT-BOOK  OF  SURGERY. 

By  :n^icholas  SEisrisr,  M.D.,  Ph.D., 

Professor  of  Surgery  in  Eush  Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic. 


^   Mi^lSTXJ^L    OF 

Materia  Medica  and  Therapeutics. 

By  a.  a.  STEVENS,  A.M.,  M.D., 
Instructor  of  Physical  Diagnosis  in  the  University  of  Pennsylvania  and  Demon- 
strator of  Pathology  in  the  Woman's  Medical  College  of  Philadelphia. 


A  MANUAL  OF  SURGERY-General  and  Operative. 

By  JOHN  CHALMERS  DA  COSTA,  M.D. 

ir 


]vo\^   liEi^oir. 


Notes  on  the  Newer  Remedies 


THETK 


THEEAPEUTIO  APPnCATIONS 
AND  MODES  OF  ADMINISTRATION. 


BY 


DAVID  CERNA,  M.D.,  Ph.D., 

Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in  the 

University  of  Pennsylvania. 


FORMING  A  SMALL  OCTAVO  VOLUME  OF  ABOUT  175 
PAGES  (7  X  5)  INCHES. 

The  work  will  take  up  in  alphabetical  order  all  the  Newer  Reme- 
dies, giving  their  physical  properties,  solubility,  therapeutic  ap- 
plications, administration,  and  chemical  formula. 

It  will,  in  this  way,  form  a  very  valuable  addition  to  the  various 
works  on  Therapeutics  now  in  existence. 

Chemists  are  so  multiplying  compounds  that  if  each  compound 
is  to  be  thoroughly  studied,  investigations  must  be  carried  far 
enough  to  determine  the  practical  importance  of  the  new  agents. 

Brevity  and  conciseness  compel  the  omission  of  all  biographical 

references. 

18  •      " 


IK  pheparation. 


DISEASES  OF  WOMEN. 

By  henry  J.  GARRIGUES,  A.M.,  M.D., 

Professor  of  Obstetrics  in  the  New  York  Post-Graduate  Medical  School  and 
Hospital ;  Gyneecologist  to  St.  Mark's  Hospital  in  New  York  City  ;  Hjnsd- 
cologistto  the  German  Dispensary  in  the  City  of  New  York;  Con- 
sulting Obstetrician  to  the  New  York  Infant  Asylum;  Obstetric 
Surgeon  to  the  New  York  Maternity  Hospital ;  Fellow  of 
the  American  Gynecological  Society  ;  Fellow  of  the 
New  York  Academy  of  Medicine  ;  President  of  the 
German  Medical  Society  of  the  City  of  New 
York,  etc.  etc. 

It  is  the  intention  of  the  writer  to  provide  a  practical  work  on 
Gynaecology,  for  the  use  of  students  and  practitioners,  in  as  concise  a 
manner  as  is  compatible  with  clearness. 


Syllabus  of  Obstetrical  Lectures 

In  the  Medical  Department,  University  of  Pennsylvania. 

By  RICHARD  C.  NORRIS,  A.M.,  M.D., 

Demonstrator  on  Obstetrics  in  the  University  of  Pennsylvania. 

Second  Edition  thoroughly  revised  and  enlarged. 

Price,  Oloth,  Interleaved  for  Notes  .  .  .  $2.00  'Eet. 

The  New  York  Medical  Record  of  April  19,  1890,  referring  to  this 
book,  says  :  "  Tliis  modest  little  work  is  so  far  superior  to  others  on 
the  same  subject  that  we  take  pleasure  in  calling  attention  briefly  to 
its  excellent  features.  Small  as  it  is,  it  covers  the  subject  thoroughly, 
and  will  prove  invaluable  to  both  the  student  and  the  practitioner  as 
a  means  of  fixing  in  a  clear  and  concise  form  the  knowledge  derived 

I'om  a  perusal  of  the  larger  text-books.     The  author  deserves  great 
edit  for  the  manner  in  wbich  he  lias  performed  his  work.     He  has 

utroduced  a  number  of  valuable  hints  which  would  only  occur  to  one 
who  was  himself  an  experienced  teacher  of  obstetrics.  The  subject- 
matter  is  clear,  forcible,  and  modern.  We  are  especially  pleased  with 
the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of 
the  child,  etc.  The  paragraphs  on  antiseptics  are  admirable  ;  there 
is  no  doubtful  tone  in  the  directions  given.  No  deta,ils  are  regarded 
as  unimportant  ;  no  minor  matters  omitted.  We  venture  to  say  that 
even  the  old  practitioner  will  find  useful  hints  in  this  direction  which 
he  cannot  afford  to  depise." 

19 


POCKET  MEDICAL  LEXICON; 

OR, 

Dictionary  of  Terms  and  Words  used  in  Medicine  and  Surgery. 
By  JOHN  M.  KEATING,  M.  D., 

Editor  of  "Cyclopsedia  of  Diseases  of  Children,  "  etc.;  Author  of  the 
"  New  Pronouncing  Dictionary  of  Medicine," 

AND 

HENRY  HAMILTON, 

Author  of  "A  New  Tran4atioii  of  VirgiPs  ^iieid  into  English  Verse;" 
Co-author  of  a  "New  Pronouncing  Dictionarj^  of  Medicine." 


Price,  75  Cents,  Cloth.     $i.oo.  Leather  Tucks. 


$o  . 

60  _| 

70 
€0 

SO   __1 

40 

30 

eo  —I 


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af  water 


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/04 

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SO 


^80*' 

—  ^^ 

—  56 
-.48 

—  31 
-.14 

__  8 


This  new  and  comprehensive 
work  of  reference  is  the  outcome 
of  a  demand  for  a  more  modern 
handbook  of  its  class  than  those 
at  present  on  the  market,  which, 
dating  as  they  do  from  1855  to 
1884,  are  of  but  trifling  use  to 
the  student  by  their  not  con- 
taining the  hundreds  of  new 
words  now  used  in  current  lit- 
erature, especially  those  relat- 
ing to  Electricity  and  Bacteri- 
olog}% 


JLnnals  of  Gyncecology, 
Philadelphia. 


.3Z*     —  ^^ 


_/^ 


e 


Saunders'  Pocket  Medical  Lexi- 
con— a  very  complete  little  work, 
invaluable  to  every  student  of 
medicine.  It  not  only  contains  a 
very  large  number  of  words,  but 
. —  jjf  -  also  tables  of  etymological  factors 
common  in  medical  terminology; 
abbreviations  used  in  medicine, 
(From  Appendix  to  Medical  Lexicon.)     poisons  and  antidotes,  etc. 

20 


o 


— "V 


S^TJlsrDERS' 

QUESTION  COMPENDS. 

Now  the  Standard  Authorities  in  Medical  Literature 

"WITH 

Students  and  Practitioners  in  every  City  of  the  United  States 

and  Canada. 


THE  REASON  WHY ! 

They  are  the  advance  guard  of  "  Student's  Helps  " — that 
DO  HELP ;  they  are  the  leaders  in  their  special  line,  well  and 
authoritatively  written  by  able  men,  who,  as  teachers  in  the 
large  colleges,  know  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised 
in  the  selection  of  authors  is  fully  demonstrated  by  their 
professional  elevation.  Chosen  from  the  ranks  of  Demon- 
strators, Quiz-masters,  and  Assistants,  most  of  them  have 
become  Professors  and  Lecturers  in  their  respective 
Colleges. 

•Each  book  is  of  convenient  size  (5  by  1  inches),  containing 
on  an  average  250  pages,  profusely  illustrated  and  elegantly 
printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  subjects,  has 
been  kept  thoroughly  revised  and  enlarged  when  necessary, 
many  of  them  being  in  their  third  and  fourth  editions. 

TO  SUM  UP. 

Although  there  are  numerous  other  Quizzes,  Manuals, 
Aids,  etc.,  in  the  market,  none  of  them  approach  the  "  Blue 
Series  of  Question  Compends,"  and  the  claim  is  made  for 
the  following  points  of  excellence : — 

1.  Professional  standing  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  standard  of  text. 
2.  Size  of  type,  quality  of  paper  and  binding. 

21 


No.  1. 


ESSEITIALS  or  PHYSIOLOGY. 


H.  A.  HARE,  M.D., 

Professor  of  Therapeutics  and  Materica  Medica  in  tlie  Jefferson  Medical  Col 

lege  of  Philadelphia;  Physician  to  St.  Agnes'  Hospital  and  to  tlie 

Medical  Dispensary  of  the  Children's  Hospital ;  Laureate  of 

the  Eoyal  Academy  of  Medicine  in  Belgium,  of  the 

Medical  Society  of  London,  etc. ;  Secretary 

of  the  Convention  for  tlie  Eevision  of 

the  Pharmacopoeia,  1890. 


Crown  8vo,,  230  pages,  numerous  illustrations. 

Third  Edition,  rerised  and  enlarged  by  tlie  addition  of  a  series  of 

handsome  plate  illustrations  taken  from  the  celebrated 

"  Icones  Neryorlim  Capitis  "  of  Arnold. 

Price,  Cloth,  $1.00  net.    Interleaved  for  notes,  $1.25  net. 


Specimen  of  Illustrations. 


T/mversitij  Medical  Magazine, 
"  Dr.  Hare  has 
admirably  succeeded  in  gather- 
ing together  a  series  of  Ques- 
tions which  are  clearly  put  and 
tersely  answered." 

Pacific  Medical  Journal, 

"  Hare's  Physiology 
contains  the  essences  of  its  sub- 
ject. No  better  book  has  ever 
been  produced,  and  eyery  stu- 
dent would  do  well  to  possess  a 
copy." 

Times  and  Register,  Philadel- 
phia, '*  In  the 
second  edition  of  Hare's  Physi- 
ology all  the  more  difficult  points 
of  the  study  of  the  nervous  sys- 
tern  have  been  elucidated.  As 
the  work  now  appears  it  cannot 
fail  to  merit  the  appreciation  of 
the  overworked  student." 


23 


No.  2. 

ESSENTIALS  OF  SUR&ERY. 

CONTAINING,  ALSO, 

Venereal  Diseases,  Surgical  Landmarks,  Minor  and  Operative  Sur- 
gery, and  a  Complete  Description,  togetlier  with  full  Illustra- 
tions, of  the  Handkerchief  and  Roller  Bandage. 

By  EDWARD  MART^,  A.M.,  M.D., 

Clinical  Professor  of  Genito-Urinary  Diseases,  Instructor  lii  Operative  Sur- 
gery, and  Lecturer  on  Minor  Surgery,  University  of  Pennsylvania; 
Surgeon  to  the  Howard  Hospital ;  Assistant  Surgeon  to  tlie 
University  Hospital,  etc.  etc. 


Fourth  edition.    Crown  8yo.,  334  pages,  profasely  illustrated. 

Considerably  enlarged  by  an  Appendix  containing  full  du^ections 
and  prescriptions  for  the  preparation  of  the  various  mate- 
rials used  in  ANTISEPTIC  SURGERY ;  also  sev- 
eral hundred  recipes  covering  the  medical 
treatment  of  surgical  affections. 
Price,  Cloth,  $i.oo.     Interleaved  for  Notes,  $1.25. 

Medical  and  Surgical  Reporter, 
"  Martin's  Sur- 
gery contains  all  necessary  essen- 
tials of  modern  surgery  in  a  com- 
paratively small  space.  Its  style 
is  interesting  and  its  illustratiojos 
admirable." 

University  Medical  Magazifie, 
"  Dr.  Martin  has 
admirably  succeeded  in  selecting 
and  retaining  just  wliat  is  neces- 
sary for  purposes  of  examination, 
•and  putting  it  in  most  excellent 
shape  for  reference  and  memor- 
izing." 

Kansas  City  J^edical  Record.— 
"Martin's  Surgery.— This  admir- 
able compend  is  well  up  in  the 
most  advanced  ideas  of  modern 
surgery.'* 


Specimen  of  Illustrations. 


23 


No.  3. 

ESSENTIALS  OF  ANATOMY, 

Including  the  Anatomy  of  the  Viscera. 

By  CHARLES  B.  NANCREDE,  M.D., 

Professor  of  Surgery  and  Clinical  Surgery  in  the  University  of  Michigan. 

Ann  Arbor ;  Corresponding  Member  of  the  Royal  Academy  of 

Medicine,  Rome,  Italy ;  Late  Surgeon  Jefferson 

Medical  College,  etc.  etc. 

Fourth  edition.    Crown  8to.,  380  pages,  180  illustrations. 

Enlarged  by  an  Appendix  containing  over  Sixty  Illustrations  of 

the  Osteology  of  the  Human  Body. 

The  whole  based  upon  the  last  (eleventh)  edition  of 

GRAY'S  ANATOMY. 

Price,  Cloth,  $1.00.    Interleayed  for  Notes,  $1.25. 

Amencan  Practitioner  and 

News, 

"  Nancrede's  Anatomy. — 
For  self-quizzing  and  keep- 
ing fresh  in  mind  the 
knowledge  of  Anatomy 
gains  at  school,  it  would 
not  be  easy  to  speak  of  it 
in  terms  too  favorable." 

Southern   Californian  Practi- 
tioner, 

"  Nancrede's  Anatomy. — 

Very   accurate    and    trust- 
worthy." 

American   Practitioner    and 

News,  Louisville^  Kentucky. 

"  Nancrede's  Anatomy. — 

Truly  such   a  book   as  no 

student    can   afford  to    be 

without." 


Specimen  of  Illustrations. 


24 


No.  4. 

Essentials  of  Medical  Chemistry 

ORGANIC  AND  INORGANIC. 

CONTAINING,  ALSO, 

Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology. 

BY 

LAWRENCE  WOLFF,  M.D., 

Demonstrator  of  Chemistry,  Jefferson  Medical  College  ;  Visiting  Physician 

to  German  Hospital  of  Philadelphia  ;  Member  of  Philadelphia 

College  of  Pharmacy,  etc.  etc. 

THIRD  AND  REVISED  EDITION,  WITH  AN  APPENDIX. 
Crown  8vo.,  212  pages. 
Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 


Cincinnati  Medical  News,  "  Wolff 's  Chemistry.— A  little 

work  that  can  be  carried  in  the  pocket,  for  ready  reference  in  solving  diflBcult 
problems. ' ' 

St.  Joseph^ s   Medical  Herald,  "Dr.    Wolff  explains  most 

simply  the  knotty  and  difficult  points  in  chemistry,  and  the  book  is  therefore 
well  suited  for  use  in  medical  schools." 

Medical  and  Siirgical  Reporter,  "We  could  wish  that 

more  books  like  this  would  be  written,  in  order  that  medical  students  might 
thus  early  become  more  interested  in  what  is  often  a  diflacult  and  uninterest- 
ing branch  of  medical  study." 

Registered  Pharmacist,  Chicago,  "Wolff's  Chemistry." 

— "  The  author  is  thoroughly  familiar  with  his  subjects.  A  useful  addition  to 
the  medical  and  pharmaceutical  library." 

25 


No.  5. 

ESSEITIALS  OE  OBSTETRICS. 

By  W.  easterly  ASHTOK,  M.D., 

Professor  of  Gyiicecology  in  the  Meclico-Ghirnrgical  College  of  Philadelplna  •, 
Obstetrician  to  the  Phihxdelphia  Hos])ital. 

Third  Edition,  thoroughly  revised  and  Enlarged 
Crown  Svo.,  244:  pages,  7ailIiistratioas. 
Price,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


Specimen  of  Illustrations. 

Soiitherti  Practitio72er,  Ashton's  Obstetrics. — An  excellent 

little  volume  containino;'  correct  and  practical  knowledge.  An  admirable  com- 
pend,  and  the  best  condensation  we  have  seen." 

Chicago  Medical  Times. — "  Ashton's  Obstetrics. — Of  extreme  value  to  stu- 
dents, and  an  excellent  little  book  to  freshen  up  the  memory  of  the  practi- 
tioner." 

Medical  and  Surgical  'Reporter,  "Ashton's  Obstetrics. 

— A  work  thoroughly  calculated  to  be  of  service  to  students  in  preparing  for 
examination."' 

Neiu  York  Medical  Abstract,  ' '  Ashton's  Obstetrics  should  be 

consulted  by  the  medical  student  until  he  can  answer  every  question  at  sight. 
The  practitioner  would  also  do  well  to  glance  at  the  book  now  and  then,  to 
prevent  his  knowledge  from  getting  rusty." 

26 


No.  6. 


ESSENTIALS 

OF 

Pathology  and  Morbid  Anatomy. 


BY 


C.  E.  ARMAND  SEMPLE,  B.A.,  M.B.,  Cantab.,  I.S.A.,  M.R.C.P.,  Lond,, 

Physician  to  the  jSTortheastern  Hospital  for  Children,  Harkney  ;   Pro- 
fessor of  Vocal  and  Aural  Physiology  and  Examiner  in  Acous- 
tics at  Trinity  College,  London,  etc.  etc. 


Crown  8vo.,  illustrated,  174  pages. 


Price,  Clothf  $1.00*    Interleaved  for  Notes,  $1,25, 

From  the  College  aiid  Clinical  Record, 
"  A  small  work  upon 
Pathology  and  Morbid  Anatomy,  that  re- 
duces such  complex  subjects  to  the  ready 
comprehension  of  the  student  and  practi- 
tioner, is  a  very  acceptable  addition  to 
medical  literature.  All  the  more  modern 
topics,  such  as  Bacteria  and  Bacilli,  and 
the  most  recent  views  as  to  Urinary  Path- 
ology, find  a  place  here,  and  in  the  hands 
of  a  writer  and  teacher  skilled  in  the  art 
of  simplifying  abstruse  and  difl&cult  sub- 
jects for  easy  comprehension  are  rendered 
thoroughly  intelligible.  Few  physicians 
do  more  than  refer  to  the  more  elaborate 
works  for  passing  information  at  the  time 
it  is  absolutely  needed,  but  a  book  like  this 
of  Dr.  Semple's  can  be  taken  up  and  perused  continuously  to  the  profit  and 
instruction  of  the  reader." 

Indiajixi  Medical  Journal,  "  Semple's    Pathology  and 

Morbid  Anatomy. — An  excellent  compend  of  the  subject  from  the  points  of 
view  of  Green  and  Payne." 

CiiicivnaJi  Medical  Neu-s,  Semple's  Pathology  and  Mor- 

bid Anatomy. — A  valuable  little  volume — truly  a  mv.ltwn  in  parvo.'^ 

27 


Specimen  of  Illustrations. 


No.  7. 

ESSENTIALS 

OF 

Materia  Medica,  Therapeutics, 

AND 

PRESCRIPTION  WRITING. 


BY 


HENRY  MORRIS,  M.D., 

Late  Demonstrator,  Jefferson  Medical  College  ;   Fellow  College  of  Physicians, 

Philadelphia  ;  Co-editor  Biddle's  Materia  Medica ;  Visiting 

Physician  to  St.  Joseph's  Hospital,  etc.  etc. 


Second  Edition.    Crown  8vo.,  250  pages. 


Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 


Medical  axd  Surgical  Reporter, 

"Morris*  Materia  Medica  and  Therapeutics. — One  of  the  best  compends  in 
this  series.  Concise,  pithy,  and  clear,  well-suited  to  the  purpose  for  which  it 
is  prepared." 

Gaillard's  Medical  Journal, 

"  Morris*  Materia  Medica. — The  very  essence  of  Materia  Medica  and  Thera- 
peutics boiled  down  and  presented  in  a  clear  and  readable  style." 

Sanitarium,  New  York, 
"Morris*  Materia   Medica. — A  well-arranged   quiz-book,   comprising   tl..; 
most  important  recent  remedies." 

Buffalo  Medical  and  Surgical  Journal, 
"Morris'  Materia  Medica. — The  subjects  are  treated  in  such  a  unique  and 
attractive  manner  that  they  cannot  fail  to  impress  the  mind  and  instruct  in 
a  lasting  manner.'* 

28 


Nos.  8  and  9. 

Essentials  of  Practice  of  Medicine. 

By  HEKRY  morris,  M.D., 

Author  of  "  Essentials  of  Materia  Medica,"  etc. 

With  an  Appendix  on  the  Clinical  and  Microscopical 
Examination  of  Urine. 

By  LAWRENCE  WOLEF,  M.D., 

Author  of  "  Essentials  of  Medical  Chemistry,"  etc. 


COLORED  (VOGEL)  URINE  SCALE  AND  NUMEROUS 
FINE  ILLUSTRATIONS. 


SECOND   EDITION, 

Enlarged  by  some  THREE   HUNDRED  Essential 

Formulae,  selected  from  the  writings  of  the 

most  eminent  authorities  of  the 

Medical  Profession. 

COLLECTED  AND  ARRANGED  BY 

WILLIAM  M.  POWELL,  M.D., 

Author  of  "  Essentials  of  Diseases  of  Children." 

Post  8vo.,  460  pages. 
Price,  Cloth,  $2.00.    Medical  Sheep,  $2.50. 

Southern  Practitioner,  Nashville,  Tenn., 
"Morris'  Practice  of  Medicine. — Of  material  aid  to  the  advanced  student 
in  preparing  for  his  degree,  and  to  the  young  practitioner  in  diagnosino;  affec- 
tions or  selecting  the  proper  remedy." 

American  Practitioner  and  News,  Louisville,  Ky., 
"Morris'  Practice  of  Medicine. — The  teaching  is  sound,  the  presentation 
graphic,  matter  as  full  as  might  be  desired,  and  the  style  attractive." 

Southern  Medical  Record, 
"Morris'  Practice  of  Medicine  is  presented  to  the  reader  in  the  form  of 
Questions  and  Answers,  thereby  calling  attention  to  the  most  important  lead- 
ing facts,  which  is  not  only  desirable,  but  indispensable  to  an  acquaintance 
with  the  essentials  of  medicine.  The  book  is  all  it  pretends  to  be,  and  we 
cheerfully  recommend  it  to  medical  students." 

29 


No.  10. 


ESSENTIALS  OF  GYNECOLOGY. 


BY 

EDWIN  B.  CRAIGIjS',  M.D., 

Attending   Gynaecologist,    Roosevelt    Hospital,    Out-Patients'    Department ; 
Assistant  Surgeon,  New  York  Cancer  Hospital,  etc.  etc. 

SECOND  EDITION. 
Crown  8yo.,  186  pages,  58  flue  illustrations. 


Price,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


Specimen  of  Illustrations. 


Medical  and  Surgical  Re- 
porter, April, 1890. — "Craig- 
gin's  Essentials. of  Gyusecol- 
ogy. — This  is  a  most  excel- 
lent addition  to  this  series 
of  question  compends,  and 
properly  used  will  be  of 
great  assistance  to  the  stu- 
dent in  preparing  for  ex- 
amination. Dr.  Craigin  is 
to  be  congratulated  upon 
having  produced  in  com- 
pact form  the  Essentials  of 
Grynsecology.  The  style  is 
concise,  and  at  the  same 
time  the  sentences  are  well 
rounded.  This  renders  the 
book  far  more  easy  to  read 
than  most  compends,  and 
adds  distinctly  to  its  value. ' ' 

College  and  Clinical  Record, 
April,  1890.  —  "  Craigin's 
Grynaecology. — Students  and 
practitioners,  general  or  spe- 
cial, even  derive  information 
and  benefit  from  the  perusal 
and  study  of  a  carefully 
written  work  like  this," 


30 


No.  U. 

Essentials  of  Diseases  of  the  Skin. 

By  HEXRY  W.  STELWAGOK,  M.D., 

Clinical  Lectiirev  on  Dermatology  in  the  Jefferson  Medical  CoUejje,  Pliiladei- 
piria;  Pliysician  to  the  Skin  Service  of  the  Northern  Dispensary:  Der- 
matologist to  Pliiladelpliia  Hospital :  Piivsician  to  Skin  Department 
of  the  Howard  Hospital;  Clinical  Professor  on  Dematology  in 
the  Women's  Medical  College,  Philadelphia,  etc.  etc. 

SECOND  EDITION. 
Crown  8vo.,  262  pag-es,  74  iiliis.  many  of  which  are  originaL 


Price,  Cloth,  $!.00.    Interleaved  for  Notes,  $1.25. 


Specimen  of  Illustrations. 

New  York  Medical  Journal,  "  Stelwagon's  Diseases  of  t4t. 

Skin. — We  are  indebted  to  Philadelphia  for  another  excellent  book  on  Derma, 
tology.  The  little  book  now  before  us  is  well  entitled  "Essentials  of  Derina.- 
tology,"  and  admirably  answers  the  purpose  for  which  it  is  written."  The 
experience  of  the  reviewer  has  taught  him  that  just  such  a  book  is  needed. 
We  are  pleased  with  the  handsome  appearance  of  the  book,  with  its  clear 
typ«.  good  papei',  and  fine  Avood-cuts. " 

31 


No.  12. 

ESSENTIALS 


OF 


Minor  Surgery,  Bandaging,  and 
Venereal  Diseases. 

By  EDWARD  MARTIN,  A.M.,  M.D., 

Author  of  "Essentials  of  Surgery,"  etc. 

Crowu  8vo.,  158  pages,  82  illustrations,  mostly  specially  pre- 
pared for  this  work. 

Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25, 


Medical  News,  Phila- 
delphia, 1891. 
"Martin's  Minor  Surgery, 
Bandaging,  and  Venereal 
Diseases. —  The  best  con- 
densation of  the  subjects 
of  which  it  treatsyetplaced 
before  the  profession.  The 
chapter  on  Genito-Urinary 
Diseases,  though  short,  is 
suflBciently  complete  to 
make  them  thoroughly 
acquainted  with  the  most 
advanced  views  on  the 
subject." 

Nashville  Jouinial  of 
Medicineaiul  Surgery, 

"Martin's 
Minor  Surgery,  etc.,  should 
be  in  the  hands  of  every 
student,  and  we  shall  per- 
sonally recommend  it  toour 
students  as  the  best  text- 
book upon  the  subject." 
Pharmaceiitical  Era,   Detroit,   Michigan,  "Martin's 

Minor  Surgery,  etc. — Especially  acceptable  to  the  general  practitioner,  who 
is  often  at  a  loss  in  cases  of  emergency  as  to  the  proper  method  of  applying  a 
bandage  to  an  injured  member." 

32 


Specimen  of  Illustrations. 


No.  13. 

ESSENTIALS 


OF 


Legal  Medicine,  Toxicology, 


AND 


BY 

C.  E.  ARMAND  SEMPLE,  M.D., 

Author  of  *'  Essentials  of  Pathology  and  Morbid  Anatomy." 


Crown  8vo.,  212  pages,  130  illustrations. 


Price,  Cloth $1.00, 

Interleaved  for  Notes         ....       1,25, 


Southern  Practitioner,  Nashville, 

"Sample's  Legal  Medicine,  etc. — At  tlie  present  time,  when  the 
field  of  medical  science,  by  reason  of  rapid  progress,  becomes  so  vast, 
a  book  which  contains  the  essentials  of  any  branch  or  department  of 
it,  in  concise,  yet  readable  form,  must  of  necessity  be  of  value.  This 
little  brochure,  as  its  title  indicates,  covers  a  portion  of  medical  science 
that  is  to  a  great  extent  too  much  neglected  by  the  student,  by  reason 
of  the  vastness  of  the  entire  field  and  the  voluminous  amount  of  matter 
pertaining  to  what  he  deems  more  important  departments.  The  lead- 
ing points,  the  essentials,  are  here  summed  up  systematically  and 
clearly." 

Medical  Brief,  St.  Louis, 
"  Semple's  Legal  Medicine,  Toxicology,  and  Hygiene. — A  fair  sample 
of  Saunders'  valuable  compends  for  the  student  and  practitioner.     It 
is  handsomely  printed  and  illustrated,  and  concise  and  clear  in  its 
teachings." 


No.  14. 

ESSENTIALS  OF 

Refraction  and  Diseases  of  the  Eye. 

By  EDWAED  JACKSON,  A.M.,  M.D., 

Professor  of  Diseases  of  the  Eye  in  tlie  Pliiladelphia  Polyclinic  and  College  foi 
Graduates  in  Medicine ;  Member  of  the  American  Ophthalmological  So- 
ciety ;  Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Fel- 
low of  the  American  Academy  of  Medicine,  etc.  etc. 

AND 

Essentials  of  Diseases  of  the  Nose  and  ThroaL 

By  E.  BALDWIN  GLEASON,  M.D., 

Surgeon  in  charge  of  the  Nose,  Throat,  and  Ear  Department  of  the  Northern 
Dispensary ;  Assistant  in  the  Ear  Department  of  the  Philadelphia  Poly- 
clinic and  College  for  Graduates  in  Medicine ;  Fellow  of  the  American 
Academy  of  Medicine ;  Member  of  the  Polyclinic,  the  Pathological, 
and  the  German  Medical  Societies,  and  of  the  Northern  Med- 
ical Association  of  Philadelphia. 

Two  vols,  in  one,  crown  8yo.,  268  pages.,  .profusely  illustrated. 


Price,  Cloth,  $1.00.     Interleaved  for  Notes,  $1.25. 


University  Medical  Mag- 
azine, Philadelphia, 

' '  Jackson  and 
Gleason's  Essentials  of  Dis- 
eases of  the  Eye,  Nose,  and 
Throat.  —  The  subjects 
have  been  handled  with 
skill,  and  the  student  who 
acquires  all  that  here  lays 
before  him  will  have  much 
more  than  a  foundation  for 
future  work." 

Ne7v  York  Medical  Rec- 
ord, 

''Jackson  and  Gleason 
on  Diseases  of  the  Eye, 
Nose,  and  Throat.  —  A 
valuable  book  to  the  be- 
ginner in  these  branches, 
to  the  student,  to  the  busy  practitioner,  and  as  an  adjunct  to  more  thorough 
reading.  The  authors  are  capable  men,  and  as  successful  teachers  know 
•what  a  student  most  needs." 


Specimen  of  Eye  Illustrations. 


No.  15. 

ESSENTIALS 


OP 


DISEASES  OF  CHILDREN. 


BY 

WILLIAM  M.  POWELL,  M.D., 

Attending  Physician  to  the  Mercer  House  for  Invalid  Women,  at  Atlantic 
City,  N.  J. ;  Late  Physician  to  the  Clinic  for  the  Diseases  of  Chil- 
dren  in  the  Hospital  of  the  University  of  Pennsylvania  and 
St.  Clement's  Hospital ;  Instructor  in  Physical  Diag- 
nosis in  the  Medical  Department  of  the  Uni- 
versity of  Pennsylvania,  and  Chief  of 
the  Medioal  Clinic  of  the  Phil- 
adelphia Polyclinic. 


CROWN  8vo.,  216  PAGES. 
Price,  Cloth,  $1.00    Interleaved  for  Notes,  $1.25. 


American  Practitioner  and  News,  Louisville,  Ky., 

"Powell's  Diseases  of  Children. — This  work  is  gotten  up  in  the 
clear  and  attractive  style  that  characterizes  the  Saunders'  Series.  It 
contains  in  appropriate  form  the  gist  of  all  the  best  works  in  the  de- 
partment to  which  it  relates." 

Southern  Practitioner,  Nashville,  Tennessee, 
"  Dr.  Powell's  little  book  is  a  marvel  of  condensation.     Handsome 
binding,  good  paper,  and  clear  type  add  to  its  attractiveness." 

Annals  of  Gynecology,  Philadelphia, 
"  Powell's  Diseases  of  Children. — The  book  contains  a  series  of  im- 
portant questions  and  answers,  which  the  student  will  find  of  great 
utility  in  the  examination  of  children." 

35 


No.  16. 

ESSENTIALS 


OF 


EXAIIIATIOI  OE  TJEIIE. 


BY 


LAWRENCE  WOLFF,  M.D., 

Author  of  "Essentials  of  Medical  Chemistry,"  etc. 


COLORED  (VOGEL)  URINE   SCALE  AND  NUMEROUS 
ILLUSTRATIONS. 


Crown  8vo.    Price,  Cloth,  75  Cents. 


Specimen  of  Illustrations. 


University  Medical  Magazine, 
June,  1890. 
"  Wolff's  Examination  of  the 
Urine. — A  little  work  of  decided 
value." 

^^^  V  Pov>,  ft  'k;      Medical   Record,   New  York., 
"-.  t^^|^.|;  5'  August  23,  1890. 

"Wolff's  Examination  of 
Urine.  —  A  good  manual  for 
students,  well  written,  and 
answers,  categorically,  many 
questions  beginners  are  sure 
to  ask." 


Memphis  Medical  Monthly,  Memphis,  Tennessee,  June,  1890. 
"Wolff's  Examination  of  Urine. — The  book  is  practical  in  char- 
acter, comprehensive  as  is  desirable,  and  a  useful  aid  to  the  student 
in  his  studies." 


No.  17. 

ESSENTIALS  OF  DIAGNOSIS. 


BY 

solomo:n"  soLis  cohe:n',  m.d., 

Professor  of  Clinical  Medicine  and  Applied  Tlierapeutics  in  the 
Philadelphia  Polyclinic, 

AND 

AUGUSTUS  A.  ESHI^ER,  M.D., 
Instructor  in  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

POST  8vo.;    382  PAGES. 

55  Illustrations,  some  of  which  are  Colored, 
and  a  Frontispiece. 


Price,  $1.50  net. 


Medical  Record,  New  York. 

*'  A  good  book  for  the  student,  properly  written  from  their  stand- 
point, and  confines  itself  well  to  its  text." 

American  Journal  of  Medical  Sciences. 

"Concise  in  the  treatment  of  the  subject,  terse  in  expression  of 
fact.  .  .  .  The  work  is  reliable,  and  represents  the  accepted 
views  of  clinicians  of  to-day. ' ' 

International  Medical  Magazine. 

"  The  subjects  are  explained  in  a  few  well-selected  words,  and  the 
required  ground  has  been  thoroughly  gone  over." 

Medical  Review,  St.  Louis. 

"We  can  heartily  recommend  this  work ;  it  is  modern  and  com- 
plete, and  will  give  more  satisfaction  than  many  other  works  which 
are  perhaps  too  prolix  as  well  as  behind  the  times." 

37 


No.  18. 

ESSENTIALS 


OF 


PRACTICE  OF  PHARMACY. 

BY 

LUCIUS   E.  SAYRE, 

Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of  Kansas. 
Crown  8vo.,  lyl  pages. 

Price,  Oloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


Albany  Medical  Anxals,  Albany,  N.  Y. 
"  Sayre's  Essentials  of  Pharmacy  covers  a  great  deal  of  ground  in 
small  compass.     The   matter  is  well  digested  and  arranged.     The 
research  questions  are  a  valuable  feature  of  the  book." 

American  Doctor,  Richmond,  Va. 
"  Sayre's  Essentials  of  Pharmacy. — This  very  valuable  little  manual 
covers  the  ground  in  a  most  admirable  manner.     It  contains  practical 
pharmacy  in  a  nutshell." 

National  Drug  Register,  St.  Louis,  Mo. 
"  Sayre's  Essentials  of  Pharmacy. — The  best  quiz  on  pharmacy  we 
have  yet  examined." 

Western  Drug  Record, 
''Sayre's  Essentials  of  Pharmacy. — A  book  of  only  180  pages,  but 
pharmacy  in  a  nut-shell.     It  is  not  a  quiz-compend  compiled  to  en- 
able a  grocery  clerk  to  '  down'  a  board  of  pharmacy  ;  it  is  a  finger- 
post guiding  a  student  to  a  completer  knowledge." 

38 


No.  20. 

ESSENTIALS  of  BACTERIOLOGY. 


CONCISE  AND  SYSTEMATIC  INTRODUCTION  TO  THE  STUDY 
OF  MICRO-ORGANISMS. 

BY 

M.  Y.  BALL,  M.D., 

Assistant  in  Microscopy,  Niagara  University,  Buffalo,  N.  Y.  ;  Late  Resident 
Physician  German  Hospital,  Philadelpliia,  etc. 

Crown  8vo.,  150  pages. 

77  Illustrations,  some  in  Colors. 

Price,  Cloth,  $1.00,    Interleaved  for  Notes,  $1,25. 


Specimen  of  Illustrations. 

Medical  News,  Philadelphia, 
*'  The  amount  of  material  condensed  in  this  little  book  is  so  great,  and  so 
accurate  are  the  formulae  and  methods,  that  it  will  be  found  useful  as  a  labor- 
atory, hand-book. " 

Pacific  Record  of  Medicine  and  Surgeby,  San  Erancisco, 

"  Bacteriology  is  the  keynote  of  future  medicine,  and  every  physician  who 

expects  success  must  familiarize  himself  with  a  knowledge  of  Germ-life — the 

agents  of  disease. 

"  This  little  book  with  its  beautiful  illustrations  will  give  the  students,  in 

brief,  the  results  of  years  of  study  and  research,  unaided." 

39 


No.  21. 

ESSEI^TIALS  OF 


Nervous  Diseases  and  Insanity, 


THEIR 


SYMPTOMS    AND  TREATMENT. 

By  JOHN  C.  SHAW,  M.D., 

Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous  System,  Long  Island 
College  Hospital  Medical  School;  Consulting  Neurologist  to  St.  Cath- 
erine's Hospital,  and  Long  Island  College  Hospital;  Formerly- 
Medical  Superintendent  King's  County  Insane  Asylum- 


Crown  8vo.,  186  pages. 
48  Original  Illustrations. 


Mostly  selected   from   the   Author's 
private  practice. 


\JPrice,  Cloth,  $1,00. 

Interleaved  for  Notes,  $1.25. 


Boston  Medical  and  Surgical 

Journal, 
"Clearly   and    intelligently    writ- 
ten." 

Medical  Brief,  St.  Louis. 
"A  valuable  addition  to  this  series 
of  compends,  and  one  that  cannot  fail 
to  be  appreciated  by  all  physicians  and 
students.'' 

Times  and  Register. 
New  York  and  Philadelphia, 

"Dr.  Shaw's  Primer  is  excellent  -as 
far  as  it  goes,  the  illustrations  are  well 
executed  and  very  interesting." 


Specimen  of  Illustrations, 


40 


No.  22. 

ESSENTIALS  OF  PHYSICS, 

BY 

FEED.  J.  BROCKWAY,  M.D., 

Assistant  Demonstrator  of  Anatomy  at  the  College  of  Physicians  and  Sur- 
geons, New  York. 


Crown  8vo.,  320  pages,  155  fine  illustrations. 
Price,  Cloth,  $1.00  net.     Interleaved  for  Notes,  $1.25  net. 


Specimen  of  Illustrations. 

American  Practitioner  and  News,  Louisville,  Ky. 

*'  The  publisher  has  again  shown  himself  as  fortunate  in  his  editor 
as  he  ever  has  been  in  the  attractive  style  and  make-ap  of  his  com- 
pends." 

Medical  Record,  New  York. 
"Contains  all  that  one  need  know  of  the  subject,  is  well  written^ 
and  is  copiously  illustrated." 

Medical  Neivs,  Philadelphia. 

"  The  author  has  dealt  with  the  subject  in  a  manner  that  will  make 
the  theme  not  only  comparatively  easy,  but  also  of  interest." 

41 


No.  23. 


Essentials  of  Medical  Electricity. 


BY 


D.  D.  STEWART,  M.D., 

Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the  Neurologi 

cal  Clinic  in  the  Jefferson  Medical  College;  Physician  to  St.  Mary's 

Hospital,  and  to  St.  Christopher's  Hospital  for  Children,  etc. 


ANB 

E.  S.  LAWRANCE,  M.D., 

Chief  of  the  Electrical  Clinic  and  Assistant  Demonstrator  of  Diseases  of  the 
Nervous  System  In  the  JefEersou  Medical  College,  etc. 


Crown  8to.,  148  pages,  65  illustrations. 


Price,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 

Med.  and  Surg.  Journal, 
Boston. 
*'  Clearly  written,  and 
affords   a  safe  guide  to 
the  beginner  in  this  sub- 
ject." 


Med.  Record,  New  York. 
"The   subject  is   pre- 
-sented   in    a  lucid    and 
pleasing  manner." 

The  Hospital,  London, 
England. 

"A  little  work  on  an 
important  subject,  which 
will  prove  of  great  value 
to  medical  students  and 
trained  nurses  who  wish 
to  study  the  scientific  as 
well  as  the  practical 
points  of  electricity." 


Specimen  of  illustrations. 


SECOND    EDITION. 

HOW  TO  EXAMINE  FOR  LIFE  INSORANGE. 

By  JOHN  M.  KEATING,  M.D., 

Medical  Director  Penn  Mutual  Life  Insurance  Co. ;  Ex-President  of  the  Association  of  Life 

Insurance  Medical  Directors ;  Consulting  Physician  for  Diseases  of  Women  at  St 

Asnes'  Hospital,  Phila.  ;  Gynaecologist  to  St.  Joseph's  Hospital,  etc. 

With  two  large  Phototype  Illustrations,  and  a  Plate  prepared  by  Dr.  McClellan 
from  special  Dissections;  also,  numerous  cuts  to  elucidate  the  text. 

Price,    in    Clotli,    #S.OO. 

PART  I.  has  been  carefully  prepared  from  the  best  works  on  physical  diagnosis, 
and  is  a  short  and  succinct  account  of  the  methods  used  to  make  examina- 
tions ;  a  description  of  the  normal  condition,  and  of  the  earliest  evidences  of 
disease. 

PART  II.  contains  the  instructions  of  twenty-four  Life  Insurance  Companies  to 
their  medical  examiners. 


PRESS  NOTICES. 

«« This  is  the  most  practical  manual  on  this  subject  that  has  yet  been  offered  as 
a  guide  to  the  medical  examiner  for  life  insurance.  The  author  has  had  a  large 
experience  as  a  medical  director  of  one  of  the  great  life  insurance  companies, 
and  it  would,  therefore,  naturally  be  expected  that  he  would  deal  with  nothing 
but  the  useful  and  indispensable  in  a  work  of  this  kind.  Every  life  insurance 
examiner  should  possess  this  book,  even  though  he  may  be  experienced  in  this 
work,  for  it  contains  much  that  is  needful  in  the  way  of  reference  that  cannot  be 
found  grouped  elsewhere." — Buffalo  Medical  and  Surgical  Jotintal. 

"This  unpretentious  volume,  from  the  pen  of  one  of  our  most  experienced  and 
conservative  life  insurance  medical  directors,  is  just  such  a  book  as  the  young  and 
inexperienced  medical  examiner  needs.  It  is  not  a  manual  of  Medical  diagnosis, 
though  founded  upon  the  best  works  of  that  description.  It  contains  those  sug- 
gestive hints  and  recommendations  that  will  be  useful  to  the  medical  beginner 
and  that  can  only  be  furnished  by  the  man  of  experience." — The  A7nerican 
Journal  of  the  Medical  Sciences. 

- "  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance 
examination,  a  subject  of  growing  interest  and  importance.  Not  the  least  valu- 
able portion  of  the  volume  is  Part  II.,  which  consists  of  instructions  issued  to 
their  examining  physicians  by  twenty-four  representative  companies  of  this  coun- 
try. As  the  proofs  of  these  instructions  were  corrected  by  the  directors  of  the 
companies,  they  form  the  latest  instructions  obtainable.  If  for  these  alone,  the 
book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special 
branch  of  medical  science." — The  Medical  News. 

"The  volume  is  replete  with  information  and  suggestions,  and  is  a  valuable 
contribution  to  the  literature  of  the  medical  department  of  life  underwriters'  work. 
—  The  United  States  Review  (Insurance  Journal). 

"  Naturally,  in  the  prevailing  scheme  of  medical  education,  special  instruction 
in  the  peculiar  duties  of  the  insurance  examiner  can  have  no  place.  The  young 
physician  may  be  never  so  good  a  diagnostician  or  pathologist,  and  yet  fail  to  give 
satisfaction  as  a  medical  examiner.  The  book  before  us  fills  this  want." — Th^ 
University  Medical  Magazine. 

43 


TRANSACTIONS 

OP    THE 

EIGHTH  ANNUAL  MEETING 

OF    THE 

American  Climatological  Association, 

Held   at   "Wasliin^toii,  H).  O., 
September  22,  23,  24,  and  25, 1892. 

rorming  a  liandsoine  8vo.  volume  of  276  pages, 
uniform  with  the  remaiuder  of  the  series. 

I'rice,  $1.50. 


The  following  Contributions  are  included  in  the  volume : — 

J.  H.  MIISSER,  M.D.,  Whooping-cough,  its  Management 
and  Treatment. 

G.  M.  GARLAND,  M.I).,  Medical  Treatment  of  Pleurisy. 

BEVERLEY  ROBIXSON,  M  D.,  Catarrhal  Inflammations  of 
Upper  Air-tract. 

E.  L.  SHURLEY,  M.D.,  The  Sputum  in  Pulmonary  Con- 
sumption. 

EDWARD  0.  OTIS,  M.D.,  Gymnastic  Exercise  in  Chest 
Diseases. 

ALFRED  L.  LOOMIS,  M.D.,  Histological  Changes  in  Cured 
Phthisis. 

S.  A.  FISK,  M.D.,  Analysis  of  Cases  of  Phthisis. 

ROLAND  G.  CURTIN,  M.D.,  and  EDWARD  W.  WATSON, 

M.D.,  Epidemiology  of  Influenza. 
MAURICE    H.   RICHARDSON,  M.D.,    Acute  and  Chronic 

Empyema. 
WALTER  A.  JAYNE,  M.D.,  Diphtheria  at  a  High  Altitude. 
W.  W.  JOHNSTON,  M.D.,  Chronic  Diarrhoea. 
E.  H.  BOSWORTH,  M.D.,  Lymphatism. 

Etc..  Etc.,  Etc. 
u 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C2e'6381M50 

tertin 


M36 
1893 


^Essentials  rs-p 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  111  M36  1893  C.1 

Essentials  of  minor  surgery  and  bandagin 


2002102080 


